by Daniel S. Bruce, DDS, D,ABDSM and Bethany A. Bewley, RDH, MS
When adult patients with sleep-related breathing disorders come into my office for treatment, they often ask me why they developed sleep apnea in the first place. After all, it makes sense that natural selection should eliminate unfavorable traits, (such as choking in your sleep) and therefore, the genes that allow you to choke in your sleep should not exist. This apparent contradiction can be explained by delving a little deeper into the unique environment of modern man. Physical form is dictated not only by our genetic code, but also by the pressures of our environment. When the environment changes, the physical human form can change. This is the classic nature versus nurture discussion. Also, the benefits of a certain characteristic may outweigh the drawbacks. For example, the ability to communicate through speech is highly valuable to humans despite the necessity of a collapsible airway to do so.
I was first introduced to the concept of Darwinian medicine in college while reading the book “Why We Get Sick.” One aspect of the theory is that our bodies are suited to ideally develop in conditions similar to those of Paleolithic times. Humans ate large quantities of raw, unprocessed food unfortified with nutrients and very little sugar. They had to deal with infections, bacteria and parasites on a daily basis. Paleolithic humans lived in an environment with different types of stressors and different types of toxicities. Our bodies are designed to function in the Paleolithic environment. This concept was applied to the world of dentistry by Dr. Kevin Boyd in his article on Darwinian Dentistry in 2012.2 He noted that the raw, hard food humans ate before the advent of agriculture created wide, more protrusive dental arches with a more balanced posture and thus a larger airway less prone to collapse. Reading this article was an “aha” moment for me that helped me understand the role our environment plays in the development of the human airway.
Does this make you curious about ideal growth and development? It should! Understanding the topic helps dentists assess where things can go wrong, why they went wrong, and what environmental and functional roadblocks can be removed to allow full expression of our growth potential. With this in mind, here are a few risk factors kids have for developing sleep apnea as a child or later on as an adult.
A “tongue-tie” or “tethered oral tissue” or “ankyloglossia” occurs when a band of tissue tethers the tongue to the floor of the mouth. This situation can result in problems breast feeding, swallowing, and speaking. Very simply put, the tongue is a very good (actually the most ideal!) orthodontic expansion device. An ideal tongue posture occurs when the mouth is closed and the tongue is between the arches sitting fully on the palate. An ideal swallow occurs when the tongue pushes food to the roof of the mouth after chewing and peristaltically moves the food down the throat. The action of chewing and a tongue-to-roof-of-mouth swallow helps to develop the maxilla and mandible in three dimensions.
A tongue-tie restricts the ability of the tongue to support the maxillary arch. This often results in an underdeveloped maxilla and can affect the ability of the mandible to develop normally. The solution for a patient with a tongue-tie is a lingual frenectomy. However, this needs to be performed in conjunction with myofunctional therapy in order to re-train the tongue to function ideally. If this sounds like hard work, it is! However, it is necessary to restore function in most cases. Just because the tongue now has the ability to function ideally, does not mean it will forget the old swallow patterns. A myofunctional therapist is a hygienist or speech therapist with additional training in the function of the tongue. Finding and partnering with a trained therapist greatly enhances any effort to shape ideal growth.
Mouth breathing is incredibly common in children. Allergies, low muscle tone, tonsil and adenoid hypertrophy, and even tongue-tie can cause mouth breathing. When a child breathes through his or her mouth, the tongue cannot sit between and develop the arches. The result is retrusion and collapse of the maxilla and often the mandible.
Screening for mouth breathing is as easy as observing the child at rest. Also, crowded teeth or lack of space in the primary dentition are big red flags. Often kids that mouth breathe have heavy plaque levels, gingivitis (especially in the anterior teeth), and may have high caries rates due to xerostomia. Treatment involves referring for a sleep study if risk factors for sleep apnea are present or to an ENT to assess the reason for nasal congestion. The local myofunctional therapist can also be of assistance by teaching the patient exercises to change the resting posture of the tongue and aid in nasal breathing.
Hypertrophic adenotonsillar tissue has a direct correlation with sleep apnea in children. The benefits of removing the tonsils and/or adenoids can be seen dramatically and immediately. Improvement in school performance has been shown, as well as improvement in sleep disordered breathing.3
However, it is extremely important to realize sleep-related breathing disorder symptoms can recur in some patients and tonsillectomy may not be the first line therapy for all patients. Myofunctional therapy can improve outcomes after surgery and reduce the risk of relapse later in life.4 In addition, orthodontic expansion has been shown to be helpful in necessary cases. Reasons for adenotonsillar hypertrophy are complex and having a team treatment approach is necessary for persistent results.
Figure 1: Tongue tie in a 6 year old
Figure 2: Unilateral crossbite, likely a result of low tongue posture secondary to a tongue tie
Figure 3: Hypertrophic tonsils. Note the red and chapped lips, a common finding in mouth breathing children.
The following photos are of a six-year-old female patient who presents with mouth breathing, adenotonsillar hypertrophy, tongue-tie, and maxillary crossbite. However, the parents do not report fatigue, snoring, or other issues associated with pediatric SRBDs. Since not all patients with risk factors have disease, we focused on dental arch development and removing barriers to ideal growth and development. The treatment plan therefore included orthodontic expansion, a lingual frenectomy, and myofunctional therapy. Pediatrician or pediatric ENT evaluation of tonsils was also recommended. Finally, the patient was referred to a pediatric functional medicine physician to assess environmental, food-related, or other interactions that might cause hypertrophy of the tonsils and adenoid tissue. Without parental observations of SRBD, we didn’t push for a sleep diagnosis, but focused on that ideal growth and development. I’m happy to report that she is currently in treatment – we felt that insisting on a sleep study might have delayed treatment, and it wasn’t necessary for this treatment plan.
Where to go from here
The risk factors for developing a sleep-related breathing disorder in kids are often complex. Every child responds to resistance of the airway differently. The lethargic kids who snore and gasp for air at night are easier to identify, but you have to look beyond the teeth and at the whole patient. It is also important to remember every kid responds differently to airway stress. OSA may contribute to ADHD symptomatology, with these symptoms improving with ADHD treatment in a subset of patients.5 There are likely genetic, epigenetic, environmental, nutritional, digestive system, immune system, physiologic and other factors at play. A holistic approach is helpful in getting kids on the best treatment path. I have found help in navigating this journey through the American Sleep and Breathing Association, the American Association or Gnathologic Orthopedics, the American Academy of Dental Sleep Medicine, and the American Academy of Physiologic Medicine and Dentistry, to name a few. SRBDs in children are a huge problem and appear to be getting worse, setting them up for life-altering challenges as adults. I hope to see the pattern of increased attention, research, and open-minded thought in this area continue. The best thing we can do as dentists is educate ourselves on treatment options, help educate parents about the problem so they can take ownership in finding solutions, and develop a comprehensive referral network. This is a complex problem in which the solutions may or may not be simple. However, I believe a truly integrative dental practice needs to have at least a baseline knowledge of the role of the airway in human development and the risk factors that can put our patients at risk for airway disorders.
- Nesse, R. M., & Williams, G. C. (1994). Why we get sick: The new science of Darwinian medicine. New York: Times Books.
- Boyd, Kevin. (2011). Darwinian Dentistry: An Evolutionary Perspective on Malocclusion, Part I. Journal of the American Orthodontic Society, Nov/Dec, 34-39.
- Gozal, D. (1998). Sleep-disordered breathing and school performance in children. Pediatrics, 102, 616–620.
- Camacho, M., Certal, V., Abdullatif, J., Zaghi, S., Ruoff, C.M., & Capasso, R. (2015). Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep, 38(5), 669–675. doi: 10.5665/sleep.4652
- Is obstructive sleep apnea associated with ADHD? Youssef NA, Ege M, Angly SS, Strauss JL, Marx CE. Ann Clin Psychiatry. 2011 Aug;23(3):213-24. Review.