HEALTHY BREATHING IS NASAL BREATHING

By Steve Carstensen, DDS

You think you’ve successfully managed your patient’s sleep apnea with the oral device you carefully chose and expertly fitted. The apnea-hypopnea index (AHI) is below five; the oxygen levels are always higher than 90%. Could they still be unhealthy?

People who breathe through their mouths, with or without upper airway collapse, are not healthy. Dentists are trained to look for signs of periodontal disease and ask about halitosis or changes to taste — did you know these are some of the most common symptoms of mouth breathing? We are the only medical professionals who address these health and quality-of-life issues with expertise.

Dentists are the only health care providers trained to fit manufactured devices to the teeth. Sleep-related breathing disorders can be managed by posturing the jaw forward to stent the airway open, and the easiest way to do that is to create a custom oral device. Therapy is often not free from side effects which require a dentist’s skills to address.

Pulmonologists and other physicians have deep knowledge of the entire physiologic process of respiratory health. But if air cannot pass the upper airway or arrives at the delicate lung tissue cold, dry and dirty, doctors and patients must work much harder to achieve homeostasis.

Screening your patients for sleep-related breathing disorders involves asking eight simple questions — two such instruments are the Epworth Sleepiness Scale and STOP-BANG — and discussing the results. The American Dental Association adopted a policy statement in 2017 encouraging dentists to step up and be part of the breathing disorder solution by screening their patients. A simple screen for nose breathing is to ask your patient to keep their lips together for two minutes while breathing normally through their nose. If they ‹must› part their lips, take visibly deeper and more effortful breaths, and/or feel like they are not getting enough air, they are mouth breathers.

Mouth breathing is more harmful than its unpleasant appearance would imply. Let’s compare the function of the oral tissues to that of the nasal passage from the nares to the palate: l The nose humidifies the air. In the mouth, the air robs oral mucosa of its moisture. l The nose brings outside air to body temperature by the time it hits the back of the nose. l The nose filters the air of particulates. The air passing through the mouth moves unhindered, full of whatever is in the environment. l Nitric oxide produced in the paranasal sinuses diffuses into the air passing through the nose. Oral mucosa produces no nitric oxide. l Microbes, such as bacteria and viruses, are killed by nitric oxide. l Deep in the lungs, thin-walled alveoli facilitate gas exchange with the blood. A surfactant that cannot be produced without nitric oxide keeps these weak tissues from sticking to each other. l To keep the capillaries in the lungs open for blood flow, the smooth muscles in vessel walls maintain tone facilitated by the diffusion of nitric oxide from inspired air into the alveolar walls. l Oral mucosa produces no nitric oxide. Repeated for emphasis. l A regular airflow pattern in the nose sends electrical signals to the limbic system — the part of the brain controlling memory, emotion, cognition and influencing the autonomic nervous system. That implies unsettled science, but the presence of the signals with nose breathing, not mouth breathing, has been verified in humans. l Air expired through the nose is de-humidified, preserving body hydration. Air passing over the lips carries water, depleting this vital resource’s body.

As dentists become more involved in fundamental health concerns like breathing, the services provided must reflect more than basic dental education. Dentists must claim their area of expertise as the only health care providers who can do what they do but also expand their view beyond the oral cavity to consider the function of the adjacent tissues. Assessment and therapy aimed at nasal breathing improvements widen the scope of what dentists can do to help people get healthier without diminishing the critical contributions dentists are already making. This expansion of service has not yet become part of the dental school curriculum — thankfully, our profession is one of continual learning.

As clinician-scientists, we love to see numbers — and objective data about nasal breathing performance is possible with specialized equipment just coming into dentistry from the Ear, Nose & Throat world.

Just like an AHI, we can measure nasal breathing. Normalizing AHI and SpO2 without considering what else the body must compensate for on the journey to homeostasis is not optimum health care. It’s not good enough to ‘hit the numbers’ of obstructive events and blood oxygen nadirs.

What Can Dentists do to Encourage Nose Breathing?

There are courses to learn exercises that patients can use to change habits. Medications and rinses to improve nasal airway function are within our scope to prescribe or recommend. We can provide or encourage stents for the nasal passages. During sleep, people must keep their lips together — if they wake with a dry mouth, they’ve been mouth-breathing. Simple medical paper tape strips can keep the lips from opening passively, promoting nasal breathing. If an oral device is used for stenting the oropharynx, it must allow lip closure or create a mouth seal. Above all, dentists must commit to being nose-breathing advocates and create a culture in their office where mouth breathing is no more acceptable than skipping brushing and flossing would be.

We must be good doctors to our patients. Make sure their oropharynx remains uncrowded during sleep. Help them breathe easily through their nose, every breath, every day and every night. The earlier in life the person establishes these breathing habits, the healthier they will be.

Dr. Carstensen has treated sleep apnea and snoring in Bellevue, Wash. since 1998. He’s the consultant to the ADA for sleep-related breathing disorders and heads the ADA’s Children’s Airway Initiative. He trained at UCLA’s Mini-Residency in Dental Sleep Medicine and is a Diplomate of the American Board of Dental Sleep Medicine. He lectures internationally, directs sleep education at Airway Technologies and the Pankey Institute, and is a guest lecturer at Spear Education and Louisiana State Dental School, in addition to advising several other sleep-related manufacturers. In 2014, he helped found Dental Sleep Practice Magazine and currently serves as Chief Dental Editor. In 2019, Quintessence published A Clinician’s Handbook for Dental Sleep Medicine, written by a co-author.

Dr. Carstensen will offer “Dental Sleep Medicine Intensive: A Two-day Mini-residency” (MR01) – Friday, June 30 and Saturday, July 1, 9 a.m.-5 p.m, both days. Learn more about Dr. Carstensen’s course being offered at the 2023 Florida Dental Convention at floridadentalconvention.com.

3D PRINTING WORKSHOP FOR THE EVERYDAY DENTIST (W16)

FRIDAY, JUNE 30 | 9 AM-5 PM | CE CREDIT: 7

TRACK: DENTAL MATERIALS | AUDIENCE: DENTISTS & ASSISTANTS

DIGITAL SMILE DESIGN WORKSHOP (W24)

SATURDAY, JULY 1 | 8 AM-12 PM | CE CREDIT: 4

TRACK: RESTORATIVE | AUDIENCE: DENTISTS

In this full-day 3D printing hands-on workshop, attendees will learn what 3D printing is, how it is used in dentistry and get to experience the workflows, materials and design themselves. This workshop will start off with an overview of the dental indications for 3D printing followed by a simple four-step workflow for success in your practice come Monday morning. Overview of design for nightguards, surgical guides and flippers will be shown as well as hands-on learning with the printers and materials themselves. The full-day workshop will wrap up with an understanding of post processing and how to successfully implement this into a busy practice. A one-hour break for lunch will be provided during this course. Attendance is limited to 30.

Digital smile design is one of the greatest keys to closing more aesthetic cases, understanding and treatment planning them appropriately, and delivering amazing results. This workshop will go through an overview using exocad software to show what can be done with digital mockups. Using photography, intraoral scans and trial smiles, you can simulate exactly what a patient could get with cosmetic dentistry and show them, not only digitally, but how to transfer that to the patient’s mouth. Attendees will learn how to transfer digitally-designed smiles to the patient’s mouth and how to use those for fabricating long-term temporaries that could be preprinted. This workshop will leverage the fundamentals of solid smile design with the future of cosmetic dentistry. Attendance is limited to 30.

Participant Requirements for both workshops: Laptop Computer

The equipment for both workshops are partially sponsored by

Dr. Richard (Sully) Sullivan earned his dental degree from the University of Tennessee College of Dentistry. He is an instructor at 3D Dentists and has a private practice in Brentwood, TN.