Mouth Breathing & Adverse Effects | Dr. Mark Sayed
A vast majority of health care professionals are unaware of the negative impact of upper airway obstruction (mouth breathing) on normal facial growth and physiologic health. Children whose mouth breathing is untreated may develop long, narrow faces, narrow mouths, high palatal vaults, dental malocclusion, gummy smiles, and many other unattractive facial features, such as skeletal Class II or Class III facial profiles. These children do not sleep well at night due to obstructed airways; this lack of sleep can adversely affect their growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity.
It is important for the entire health care community (including general and pediatric dentists) to screen and diagnose for mouth breathing in adults and in children as young as 5 years of age. If mouth breathing is treated early, its negative effect on facial and dental development and the medical and social problems associated with it can be reduced or averted.
This patient illustrates how untreated mouth breathing in children can cause abnormal myofunction. Left untreated, this condition can adversely affect normal facial growth and dental development.
At age 6, the child had normal facial features; however, her mouth breathing went untreated. By age 9, the child had developed a long, narrow face and severe dental malocclusion. She was successfully treated using functional appliance therapy.
Negative Impact of Sleeping Disorders
The negative impact of sleeping disorders on growth and development has been substantiated in many studies. Many children with sleep disorders are often well below their peers in terms of height and weight.
Other major issues beyond abnormal facial and dental development also have been associated with mouth breathing. Studies have shown that upper airway obstruction/mouth breathing can cause sleep disorders and sleep apnea. Studies have shown that children with sleep disorders have problems paying attention in school, are often tired, and may exhibit behavior problems; many of these children often are misdiagnosed with attention deficit hyperactivity disorder (ADHD). The current standard of care for children, adolescents, and adults with ADHD is medication with such stimulant drugs as Adderall (Shire US Inc.) or Ritalin (Novartis Pharmaceuticals). These medications have raised concerns about reduced height and weight, cardiovascular effects, tics, evidence of carcinogenic and reproductive effects, and substance abuse.
ADHD is the most commonly diagnosed behavioral disorder in children; however, many of these children have sleep disorders and are being misdiagnosed. In the author’s opinion, the ideal treatment for these children involves treating the blocked airway, allowing the child to breathe through the nose rather than the mouth. Mouth breathing irritates the mucosa, and these children often will have swollen tonsils and adenoids, one of the major causes of upper airway obstruction, sleep disorders, and sleep apnea. Surgical removal of swollen tonsils and adenoids is highly recommended when they negatively affect sleep. With surgical removal of swollen tonsils and adenoids, many of these children who were misdiagnosed with ADHD have shown marked improvement in behavior, attentiveness, energy level, academic performance, and growth and development; in addition, nocturnal enuresis was corrected.
The Dentist’s Role In The Diagnosis And Treatment Of Mouth Breathing
General and pediatric dentists may be in the best position to screen and treat patients who suffer from upper airway obstruction/mouth breathing. Dentists usually see patients on a regular basis, every six months, and swollen tonsils can be easily detected by using a mouth mirror to look at the back of the patient’s throat. All patients – children, adolescents, and adults – should be screened for upper airway obstruction.
The diagnosis and treatment of mouth breathing (and all of its associated medical, social, and behavioral problems) is best managed by using a multidisciplinary approach involving pediatricians, physicians, dentists, and ear-nose-throat (ENT) specialists.
Using the clinical observations cited in the table, pediatricians, physicians, and dentists are the primary care providers who can diagnose mouth breathing and sleep disorder problems; these patients should be referred to an ENT specialist for further evalua- tion and treatment. As previously noted, surgically removing swollen tonsils and adenoids has improved nasal respiration, sleep, behavior problems, and academic performance. Many athletically inclined children will actively seek treatment when they understand that it will improve their respiration and enhance their athletic performance.
Although surgical removal of swollen tonsils and adenoids should be the first line of treatment for individuals with upper airway obstruction, patients who also exhibit narrow palates and high palatal vaults may require additional dental treatment. These conditions result in narrow and compressed sinuses, which can inhibit nasal respiration.
This second line of treatment should be provided by dentists, who can correct facial and dental abnormalities with functional appliances. Various functional appliances, such as Frankel II and Herbst, have been used to open retrognathic mandibles, which tend to close the pharyngeal airways. These patients need palatal expansion to open the nasal sinuses, which will allow for more efficient nasal respiration. According to the literature, a combined therapy of adenotonsillectomy and palatal expansion significantly improved sleep and nasal respiration while alleviating the symptoms of ADHD.
A 5-year-old boy was seen by a pediatric dentist who understood the problems associated with mouth breathing. The dentist immediately referred him to an ENT specialist, and his tonsils and adenoids were surgically removed; at that point, the child was referred to the author for orthodontic treatment. The patient was skeletal Class II (mandibular retrognathic), dental Class II, division 1. An occlusal view showed minimal crowding; however, the boy had moderately narrow maxillary and mandibular arches with a high palatal vault.
A diagnostic screening revealed that the patient was too young to have developed a long, narrow face; however, he had the typ-
ical “adenoid facies” that is indicative of upper airway obstruction/mouth breathing and sleep disorder. In addition, the patient’s height and weight were well below average for his age. In the patient’s health questionnaire, his mother noted that he slept with his mouth open, he tired easily during the day and was easily winded, and he had severe behavior problems in school, throwing temper tantrums to the point where his teacher would have to call on the patient’s older brother to calm him. The patient was unable to concentrate in school and was failing most of his subjects.
Since the patient had a moderately narrow palate and high palatal vault, palatal expansion was indicated. Maxillary and mandibular Schwarz appliances were used to expand both the maxillary and mandibular arches during Phase I removable appliance therapy.
Even after only one year of expansion therapy, the patient’s mother claimed to observe significant improvements in many areas, noting that the patient slept better, had a better disposition, was more energetic and willing to participate in activities, stopped bed wetting within seven months after the start of therapy, experienced a significant growth spurt, had a better appetite, and improved speech. In addition, while the patient had been failing most of his subjects, he recently took a standardized achievement test used in the U.S. to assess K-12 student achievement and posted combined reading, language, and math scores in the 99th percentile.
Sleep disorder/sleep apnea is a widespread and prevalent condition that has profound effects on the health and well-being of all who suffer from it. Many patients may develop emotional and psychological problems in addition to physical and medical problems. Without treatment, these individuals will place an enormous financial burden on the health care system and on society as a whole. These patients can be treated successfully by using the multidisciplinary approach discussed in this article.
Although a preponderance of studies show the direct correlation between mouth breathing and abnormal facial growth and sleep disorder/sleep apnea, not enough information is available about this correlation. This article is presented in the hope that both health care professionals and the public will become more knowledgeable about, and more vigilant in, assessing mouth breathing in children and adults, thus alleviating the many emotional, physical, and psychological problems associated with this condition.
Compliments of Mark Sayed Orthodontics
San Juan Capistrano