Airway Dentistry in Napa

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As a dentist, Dr. Newberry realizes that he is in a unique position to screen and educate people on systemic diseases, such as diabetes, cardiovascular disease, and oral cancer, particularly because people may visit their dental office more often than their doctor. More recently, he and his dental hygienists and assistants are also being trained to identify signs of airways issues and sleep disordered breathing, such as snoring and sleep apnea, as often there are many clues that present in the oral cavity. We see many signs of sleep disordered breathing, such as grinding/clenching at night (aka bruxism), TMJ pain, blocked airway, tongue thrusts, and bite issues for example. Our goal is to help you be the healthiest and happiest version of yourself, and as such, we will always take the time to help educate you about these conditions and any ties they have to the oral environment and your overall health.

WHAT IS SLEEP DISORDERED BREATHING?

Sleep disordered breathing describes a group of sleep breathing issues involving:

  1. Abnormal respiratory patterns such as loud or chronic snoring, apnea, and/or hypopneas
  2. Insufficient ventilation during sleep, stemming from systemic disease or anatomical issues which may cause narrowing of the breathing passages

An apnea is when a person stops breathing for at least 10 seconds, before “waking up” to take a breath. A hypopnea is when a person’s breathing becomes shallow for 10 seconds or more. Their blood levels of oxygen may drop, but they don’t actually stop breathing completely.

Experts agree that things like mouth breathing, light snoring, noisy or effortful breathing, fitful sleep, multiple awakenings at night, insomnia, bed wetting, etc. are also signs that a person may have a sleep breathing problem.

When breathing is impaired, you may not be getting sufficient oxygen to your brain and tissues while you sleep, or your body may be making compensations night after night to open the airway, which can leave you exhausted in the morning. This nightly battle may manifest in many different health concerns, such as high blood pressure, migraines, gastrointestinal disorders, autoimmune diseases, and depression and anxiety to name a few, which are often overlooked as having a basis in a lack of quality sleep.

CAUSES AND DIAGNOSIS

There are many reasons a person may develop sleep apnea, and similar sleep disorders, at any stage of life. Some of the most common are weight gain, large tonsils or adenoids, respiratory problems like asthma, allergies, COPD, nasal obstruction, a narrow palate leading to reduced room for the tongue and smaller nasal passages, and loss of tone in the airway and tongue muscles.

If you or your doctor suspect that you have a sleep breathing issue, he or she may order you a sleep study, which can either be done at home (Home Sleep Test), or in a laboratory overnight (Polysomnogram). If you, or your doctor, aren’t totally convinced enough to order a test for you or a family member, you can also track your sleep at home with free Apps like SnoreLab, or with devices like the Apple Watch or FitBit. Videoing a sleeping child or spouse at night can also be very revealing. This data can give you and your doctor more information to see if a more in-depth test is needed.

Sleep studies, particularly those done in a lab overnight, will tell you if you are suffering from one of many sleep disorders. Some common diagnoses patients receive are:

  1. Sleep Apnea: Characterized by loud snoring, choking noises, and pauses in breathing leading to oxygen deprivation. A patient will be diagnoses as Mild, Moderate or Severe, depending on how many apneas and hypopneas they have throughout the night. This score is called the Apnea Hypopnea Index (AHI).
  2. Upper Airway Resistance Syndrome (UARS): Often called the “young, fit, female disease,” this sleep disorder is characterized by the narrowing of the airway, not a cessation in breathing like in sleep apnea. This leads to poor sleep and daytime fatigue because the body compensates to open up the airway all night. It is harder to diagnose, as traditional sleep studies look for apneas and hypopneas, which these patients might not have. They also tend to be young and of healthy weight, so doctors might overlook a sleep disorder as the main cause of ailments such as jaw and facial pain, headache/migraine, IBS, chronic fatigue, depression and anxiety, etc.
  3. Insomnia: Described as problems falling or staying asleep. This can be short-term, due to major life events or stressors, or a more chronic form, which is less common, but can be seen in conjunction with UARS.

Restless Leg Syndrome (RLS), Narcolepsy, and REM Sleep Behavior Disorder are also common diagnoses from a sleep study.

If you suspect you, or someone in your family, is suffering from a sleep disorder talk to your doctor and Dr. Newberry at your next dental visit. We are fortunate to have many good sleep clinics and providers here in Northern California, such as Stanford Sleep Medicine Center.

SIGNS IN THE MOUTH

Over the last several years, there has been a wave of new research demonstrating that many dental issues may have airway problems as a root cause. Dental concerns such as Temporomandibular Joint Disorder (TMJ/TMD), orthodontic issues, narrow jaws, tooth wear, clenching and grinding, cavities, dry mouth, and gum disease, can all be signs of sleep-disordered breathing. Dr. Newberry and his clinical team are trained to examine the upper airways, including the mouth, jaw, nasal passages, tongue and throat, to help screen for airway issues and make the proper referrals to treat sleep breathing issues on a dental-medical team.

For example, if Dr. Newberry suspects an issues with nasal obstruction, or sees large or infected tonsils, he may refer a patient to an Ear Nose and Throat doctor (ENT), who can perform an evaluation, order a sleep study, or prescribe certain medications or surgical interventions to treat the airway.

However, obstructed breathing can also be partially brought on by oral issues, such as a narrow palate or problems with your bite. In these cases, Dr. Newberry may also be able to help with restorative dentistry, or he may refer you to an airway orthodontist or oral maxillofacial surgeon. These specialists now have many tools and procedures that can help expand and bring jaws forward to help open up the airway and leave more room for the tongue to sit in the mouth.

Dr. Newberry may also refer you to a Myofunctional Therapist, who can help strengthen the muscles of the face, lips, tongue, and airway muscles, to facilitate better nasal breathing and tongue rest posture during the day and at night.

Some oral signs Dr. Newberry and team can check for:

  • Tooth wear from bruxism. (clenching and/or grinding of the teeth), or “airway acid reflux”
  • Effects of mouth breathing, such as red and swollen gums, recurrent tooth decay
  • Enlargement of tonsils/narrowing of back of the throat
  • Jaws that pop when you open and close your mouth
  • Tongue and lip tie

DENTAL TREATMENT OPTIONS FOR SLEEP APNEA

A poor bite, missing teeth, misaligned or narrow jaws and other dental abnormalities can further cause breathing problems. Depending on the particular issue, your dentist, orthodontist, or oral surgeon can correct them. Treatments include:

  • Night Guard: Worn during sleep, this device can help prevent tooth grinding, as well as temporarily opening the bite to give the tongue more space, which can improve milder sleep breathing issues at night.
  • Mandibular Advancement Device (AKA snoreguard): This is a removeable night time devices that temporarily moves the jawbone forward, opening the airway, especially for patients with sleep apnea. It is worn during sleep with or without a CPAP machine. It is can be more comfortable than the CPAP for some people and can also improve sleep apnea, snoring, and bruxism. It may be covered by medical insurance when a patient has a sleep apnea diagnosis from a sleep study.
  • Palatal Expander: Attached to the teeth, or in some cases the palate itself, this device can widen a child’s upper jaws to correct occlusion issues such as crossbite, crowding and impacted teeth. It is important to begin this treatment as early as possible in childhood, while palates are still malleable, because adults’ palates essentially fuse and don’t respond as readily to these appliances, without surgical intervention. Palatal expanders can be an important component of treatment to reduce sleep apnea and restore proper functional nasal breathing. This is because the roof of the mouth is the floor of the nose, so by expanding the palate you effectively widen the nasal passageway. Pediatric dentists and orthodontists are being called to screen for airway issues and refer for expansion earlier and earlier, starting as early as age 3 or 4, since much of jaw and facial growth happens by age 6. Orthodontic correction and expansion with traditional orthodontics can still be helpful in adults to correct bites and leave more room for the tongue. There are also newer, more sophisticated techniques such as Surgically Facilitated Orthodontic Therapy (SFOT), mini-implant supported (TAD) expanders, Surgically Assisted Rapid Palatal Expansion (SARPE) and the DOME technique developed by Dr. Audrey Yoon, which can all allow for adults to form new bone in the palate or on the front of the jaw, and thus expand to improve the airway.
  • Tongue and Lip Tie Release: Dr. Newberry and his hygienists have taken specialized training from Dr. Soroush Zaghi, MD, who has become the leading expert and researcher on tongue and lip tie in adults and children. He has developed an assessment to identify functional issues with tongue range of motion caused by a tongue tie and performs Functional Frenuloplasties to restore proper nasal breathing and tongue posture and thus treat sleep breathing disorders, along with myofunctional therapy. You can find out much more about tongue tie, and other issue related to sleep on his websites thebreathinstitute.com and zaghimd.com.
  • Jaw Surgery: In severe cases of sleep apnea, jaw surgery known as Maxillomandibular Advancement (MMA) may be an option. Performed by an Oral Maxillofacial Surgeon (OMS/OMFS), this form of facial skeletal surgery is done by making incisions inside the mouth in the bone in order to bring both jaws forward to leave more space for the tongue and open up the airway. It is often done in conjunction with orthodontics.

MYOFUNCTIONAL THERAPY

Our office is one of the few in the area with hygienists on our team who are trained in myofunctional therapy. Our hygienist Krista has taken advanced training in this area and has been doing myofunctional therapy for over a year. Jenn is also starting her training this year!

Another possible cause of airway obstruction is muscle weakness of the tongue, mouth and upper throat. Myofunctional therapy consists of a system of techniques and exercises to strengthen the muscles of the lips, tongue, airway, and chewing and swallowing, enabling them to support effective nasal breathing during the day and night, which can reduce symptoms of bruxism, snoring, and sleep apnea.

Particularly in small children, it can be very effective in helping to guide jaw and facial growth. For example, by ensuring that the tongue is suctioned up to the palate at rest, myofunctional therapy can help expand jaws naturally in a developing child, and can be used along or in conjunction with orthodontics, tongue and lip tie release, and jaw surgery at any age.

Some myofunctional therapists are also breathing coaches, so they can help patients learn how to breath correctly through the nose day and night. Krista studied the Buteyko Breathing Method under Patrick Mckeown of the Buteyko Clinicic International, and is one of 16 accredited Buteyko Practicioners in California.

Myofunctional therapists are also trained to screen for anatomical issues related to the airway, such as tongue and lip tie, orthodontic issues, large tonsils, so that they can make the proper referrals to medical and dental specialists.

Myofunctional Therapy also can be useful to deter children from pushing their tongue against, and moving, their teeth, to help avoid orthodontics or orthodontic “relapse,” and helping parents eliminate bad habits like pacifier use, thumb sucking, or nail, tongue or cheek biting.

If you think you have sleep breathing issues, discuss them with Dr. Newberry at your next visit and visit Krista’s website Second Breath OMT for more information. It’s important to your quality of life to correct breathing problems as early as possible, and we will work with you to make sure you receive effective treatment.

ADDITIONAL READING

  1. Why We Sleep by Mathew Walker, PhD
  2. Sleep Interrupted by Dr. Steven Park
  3. The Oxygen Advantage by Patrick McKeown
  4. Gasp! Airway Health-The Hidden Path to Wellness by Dr. Michael Gelb and Dr. Howard Hindin
  5. Jaws: The Story of a Hidden Epidemic by Sandra Kahn and Paul R. Ehrlich.
  6. Tongue Tied by Richard Baxter, DMD, MS
  7. Why Zebras Don’t Get Ulcers by Robert Sapolsky, PhD