Running Head: AIRWAY DENTISTRY

Airway Centric Dentistry

By

Kari Burdick, Kalia Crook, Mary Howard

Lake Washington Institute of Technology

DHYG 412: Dental Hygiene Theory and Practice

Jolene Hartnett BS, RDH, MSEd

Fall Quarter

December 6th, 2018

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Airway centric dentistry is at the forefront of modern dentistry. It helps evaluate and treat

the alignment of teeth, the relationship of the maxilla and mandible, and the airway. These are

important things to assess because oral health has a direct impact on our overall health. Poor

alignment of the teeth, jaw, narrow palates, and a lack of tongue space puts patients at greater

risk for mouth breathing and developing breathing and obstructive sleep disorders, like sleep

apnea. Sleep apnea can cause excessive daytime sleepiness, depression, insomnia, xerostomia,

and weight gain. Airway centric dentistry helps these issues by developing extensive treatment

plans using a multidisciplinary approach to these airway issues, and often without any surgical

intervention. They also treat children to prevent and correct poorly aligned orofacial features

before the development of symptoms, and adults to address presently occurring symptoms.

Many people are familiar with the systemic health concerns related to obstructive sleep

apnea which include high blood pressure, acid reflux, hormone dysregulation, and inability to

manage anxiety, depression, emotions, and pain. A study on hormones found that “​daily

hormonal profiles are the product of a complex interaction between the output of the circadian

pacemaker, periodic changes in behavior, light exposure, neuroendocrine feedback mechanisms,

gender, age, and the timing of sleep and wakefulness” (Czeisler​, & ​Klerman, 1999).

The widely respected Spear Education Center has integrated airway analysis as an

essential aspect of the Facially Generated Treatment Planning course as well as the Esthetics,

Function, Structure, and Biology Method of care. Dr. Greg Kinzer of Spear Education stated ​“If

you’re seeing wear patients, you have to be thinking about the etiology, why is this happening?

Is it attrition? Erosion? One of the first etiological factors we need to consider is airway. If I’m

not evaluating airway, I’m doing a disservice to my patient” (Jiminez, C. 2018, para 4).
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As dental professionals we need to know traditional methods of diagnosing and treating

airway concerns before we can develop new methods of detection. We see more of the oral

cavity and airway of our patients than most medical professionals do. Medical doctors often

don’t refer patients for airway analysis until after the patient presents in a significantly diseased

state. Dental professionals have the advantage of assessing for minor airway disturbances. While

there is not a significant amount of research on some of the methods we will discuss, the

innovation process is ongoing. Diagnosis can not be done by dental professionals alone, it is

truly an interdisciplinary approach to patient care. Dr. Robert Ricketts, an orthodontist, stressed

this point when he said:

“​Respiration and mastication are biologically inseparable. The nose is a regulator, a

heater, a humidifier, a vacuum cleaner, a sterilizer and a primary sensory organ. The nasal cavity

just happens to be formed by essentially the two parts of the maxilla which also happens to be

the basal structure for the upper teeth and most of the upper jaw. The lower limits of the nasal

cavity also happen to be the upper limits of the oral cavity. What affects one affects the other. It

would appear that normal nasal breathing is conducive to normal growth of the maxilla and

normal development to the occlusion of the teeth. The well-being of the whole child may be

involved where mouth breathing is concerned, and the clinician dealing with conditions relating

to mouth breathing must look not only at the specific condition he is being asked to treat, but at

all related conditions as well. Therefore, it would seem that the time has come for the problem to

be subjected to a multi disciplined team of clinicians who can, as a team, treat the whole child."

(Rouse, J., 2017 para 4)

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Assessments must involve clinical findings, diagnostic testing, and subjective reports

from the patient. Clinical findings include intermolar width, Mallampati scores, tonsil scores,

tongue positioning/presence of tongue thrust, and occlusion. Diagnostic testing includes CBCT

with airway analysis, polysomnography (sleep study), and acoustic reflection (Demko, 2018).

The subjective concerns of the patient are essential factors to consider and include

neurobehavioral findings of stress and anxiety levels, daytime sleepiness, non-restful sleep

habits, trouble falling asleep, mouth breathing, and snoring. Physiologic parameters involve acid

reflux, high blood pressure, heart rate variability, and oxygen saturation levels. This is important

to consider as a pilot study from 2010 concluded that there is a positive correlation between

anxiety and stress by measurement of heart rate variability and malocclusion (Ekuni, Takeuchi​,

Furuta, Tomofuji, & Morita, 2010).

There are few “traditional” treatment options for sleep disordered breathing to be familiar

with. Continuous positive airway pressure (CPAP) machine is the gold standard for sleep apnea,

especially obstructive sleep apnea. It works by generating “a positive pharyngeal transmural

pressure so that the intraluminal pressure exceeds the surrounding pressure. As a result,

respiratory events due to upper airway collapse are prevented” (Tan, Tan, Chan, Mok, Wong, &

Hsu, 2018). In basic terms, the CPAP machine continuously blows gentle pressurized air into the

airway so the pressure of the tongue does not exceed it and collapse the airway. It is the most

reliable therapeutic method of treatment and is the most widely used tool to treat breathing

disordered sleep today. It is highly effective when used, but non-adherence to therapy is a major

issue. Due to the CPAP being cumbersome, uncomfortable, and awkward to some patients,

patient compliance is difficult. In order to see improvement, the patient must use the CPAP for at
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least four hours a night (Tan et al., 2018). If the patient uses the CPAP machine regularly, they

will see a significant reduction in their breathing disordered sleep symptoms and it will improve

their overall health as well.

Oral devices may be a good alternative for patients with breathing disordered sleep

symptoms who cannot tolerate the CPAP machine. The CPAP tends to be less tolerable for

patients to use regularly, so oral devices are more appealing. Oral devices are designed to

“improve upper airway configuration and prevent collapse through alteration of jaw and tongue

position” (Shdyfat & Ibrahim, 2015). These devices are worn only during sleep and work to

enlarge the airway by moving the tongue or the mandible forward. There are many different

types of oral devices, like mandibular advancement devices, tongue repositioning or retaining

devices for edentulous patients, soft-palate lifters, tongue trainers, or a combination of oral

devices and CPAP. The most common alternative to CPAP usage is the mandibular advancement

device. The device is custom fit with mechanisms to lock the device with the mandible in the

proper forward position prior to sleep (Cilil, Sapana Varma, Gopinath, & Ajith, 2015). This

modifies the posture of the tongue and airway, preventing the airway from collapsing. Oral

devices are readily available, often have better patient tolerance and adherence, and are

becoming more popular.

Although the treatment options highlighted help to control disease with devices or

appliances, they do not resolve the problem. We should never stop with just control of

symptoms, but look further for methods of resolution. Long term resolution may include

myofunctional therapy, orthodontics, or other non surgical and surgical interventions. The use of

laser ablation of the soft palate is an example of a method to consider for patients with limited
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airway without the invasive surgical intervention of a uvulopalatopharyngoplasty. It involves

multiple appointments of low energy laser activated in the tissue of the soft palate to stiffen the

tissue. The treatment is appealing as it is quick and no painful recovery involved. Most research

of this method has only been conducted on canines, although it was concluded that enough

positive results warranted the research and application in dental offices (Wang, Rebeiz, &

Shapshay, 2002).

Breathing disorders often are related to inadequate development and shape of the maxilla.

The habit of breathing through the mouth is of concern due to the fact that “​consistent open

mouth postures and mouth-breathing will change the way a jaw will grow and develop. An open

mouth posture allows for supra-eruption of the posterior maxilla and downward and backward

(clockwise) growth” (Bockow, 2017). Therefore orthodontics can be used to prevent or correct

the undesired habit of mouth breathing and address any deficiencies it may have create​d. ​The

process of bone growth and remodeling is lifelong. Orthotropics and Epigenetic Orthodontics are

considered “face focused orthodontics” and claim that tooth movement alone will not correct

physical malformations, it will only change occlusion. Using this resorption and deposition

process, treatment outcomes aim for downward relocation of the maxillary palate, sinuses, and

nasal chambers while simultaneously allowing for upward, forward relocation of the mandible

(Galella, Chow, Jones, Enlow, & Masters, 2011). Jaw growth is facilitated by an anterior growth

guidance appliance, without surgical intervention. Teeth straightening is secondary to new bone

growth and jaw development, allowing for biologically ideal jaw size, adequate room for the

tongue, and improved airway function.

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“Myofunctional Therapy is re-educating the oral facial muscles. It consists of a series of

exercises designed to create proper functions of breathing, chewing and swallowing in order to

enhance proper airway structures and functions. Myofunctional therapy also addresses the

elimination of poor habits such as thumb-sucking, nail biting, leaning, sleep positions, and

grinding and clenching” ​(airwayhealth.com, 2018). One method of retraining the facial muscles

and tongue is taping the mouth in a closed position, with the tongue resting lightly on the roof of

the mouth. Mouth taping can be performed initially during the day to acclimate the patient to the

sensation and accustom them to more conscious breathing through the nose. Myofunctional

therapy and Orthotropics are often used together to achieve desired resolution of airway

deficiencies.

Airway centered dentistry is an avenue of health that is still being discovered. More

research is needed to establish the validity of claims regarding face centered orthodontics,

however, the interdisciplinary approach to the treatment of patients should become the standard

of care. We should not stop at merely treating the symptoms of our patients but continue to push

for evidence based research establishing methods of resolution of airway deficiencies. This will

aid in eliminating many health concerns including chronic allergies, obstructive sleep apnea,

high blood pressure, acid reflux, anxiety, stress, and obesity.

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References

Airway Health | United States | Foundation for Airway Health. (n.d.). Retrieved November 20,

2018, from https://www.airwayhealth.org/

Al Ali A, Richmond S, Popat H​, et al (​ 2015) The influence of snoring, mouth breathing and

apnoea on facial morphology in late childhood: a three-dimensional study ​BMJ Open

2015;​5:​e009027. doi: 10.1136/bmjopen-2015-009027

Bockow, R., (2017, August 19). The Tongues Role in Pediatric Sleep Disorders and Skeletal

Growth and Development. Retrieved from

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-disorders-and-skeletal-growth-and-development

Buck, D., DDS. (n.d.). Balance Epigenetic Orthodontics | Orthodontist Lynnwood. Retrieved

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Cilil, V., Sapana Varma, N., Gopinath, S., & Ajith, V. (2015). Efficacy of custom made oral

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341-347. doi:http://lmcproxy.lwtech.edu:2091/10.4103/0976-237X.161881

Czeisler, C., Klerman, E., (1999), Circadian and sleep-dependent regulation of hormone release

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De Kermadec, H., Blumen, M.B., Engalenc, D., Vezina, J.P., Chabolle, F. (2014).

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Demko, G., (2018). Ten misconceptions that dentists have about treating obstructive sleep apnea.

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680702981?accountid=1553
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ay

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