Airway, Airway, Airway!
There are three things that matter in dentistry
During the past 60 years or so, the dental profession has developed a well-deserved and laudable reputation for trying to put itself out of business by emphasizing the prevention of dental caries and periodontal disease. Treating dental caries and periodontal disease comprises a large part of the revenue of most dental practices; however, dentists became enthusiastic proponents of fluoridation, emphasized proper home care, and suggested nutritional counseling—all of which greatly diminished the presence of caries and periodontal disease in many regions of the United States and the world.1
In October 2017, the American Dental Association (ADA) adopted a policy outlining the role of dentistry in screening for and treating sleep-related breathing disorders,2 which brought an additional concern onto the prevention radar. This action has helped the profession to better understand and address what may be the most obvious root cause of many dental problems—airway issues. Many in the profession have long realized that the development of dental caries is not just a result of refined carbohydrate consumption but also a result of alteration in the oral flora from mouth breathing.3 Although periodontal disease is not limited to mouth breathers, because chronic mouth breathing alters the oral flora, it shares a common etiology with caries.3
The impact of the ADA's spotlight on airway issues transcends the prevention of dental caries and periodontal disease. The profession is just beginning to understand airway's pivotal role in patients' overall or systemic health. For more than 100 years, dentists have been talking about chronic mouth breathing's effect on the occurrence of malocclusion and facial development.4 Today, the focus goes way beyond crooked teeth and the esthetics of altered facial growth to address the reduction of the size of the airway behind the soft palate and tongue that results in sleep-disordered breathing. Obstructive sleep apnea (OSA), which is an end-stage disease of this process, is now a front-page issue in the profession of dentistry.
Despite the significant morbidity and mortality associated with OSA, the presence or absence of an actual OSA diagnosis becomes less relevant as we travel further down the altered airway path and study its effects. The presence of snoring alone (without an OSA diagnosis) has been correlated with plaque formation in the carotid arteries.5 In children, reduced oxygen saturation has been correlated with brain damage,6 bedwetting, and behavioral issues such as attention deficit/hyperactivity disorder.7 An increased chance of developing hypertension in later years has also been documented.8 In adults, research demonstrates that all chronic diseases are closely correlated with poor breathing and sleeping patterns—with or without an OSA diagnosis.9
As healthcare has shifted its paradigm from thinking in terms of life span to health span, dentistry has suddenly been thrust into the center of healthcare and elevated in importance to become the gatekeeper of not just oral health but also overall health. The American Academy of Physiological Medicine and Dentistry (AAPMD) was formed a decade ago to raise awareness about airway issues, and the American Academy for Oral Systemic Health (AAOSH) was formed 12 years ago to focus on the oral-systemic connection with a greater emphasis on the microbiome and related issues. These two groups are working together to bring the dental profession to a position of prominence in treating what has now become obvious is a lifestyle issue. Like most dentists, I have spent most of my career treating the results of poor lifestyle.
Understanding that altered airways are central to everything that we treat in dentistry can help us focus on a cause rather than its symptoms. In the same manner that our profession dramatically reduced the prevalence of dental caries and periodontal disease, let us take up the challenge of preventing and treating airway issues. Let us embrace the role that the ADA has given us, take our rightful place at the center of healthcare, and make a dramatic difference in the health of both children and adults.
About the Author
William M. Hang, DDS, MSD, is the owner of Face Focused Orthodontics & Dentofacial Orthopedics in Agoura Hills, California, and he mentors clinicians through OrthO2Health.
References
1. Jepsen S, Blanco J, Buchalla W, et al. Prevention and control of dental caries and periodontal diseases at individual and population level: consensus report of group 3 of joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J Clin Periodontol. 2017;44(Suppl 18):S85-S93.
2. ADA House of Delegates. The role of dentistry in the treatment of sleep related breathing disorders. ADA website. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/the-role-of-dentistry-in-sleep-related-breathing-disorders.pdf. Published October 2017. Accessed February 23, 2022.
3. Harvard Health Letter. Harvard Health Publishing. August 6, 2015.
4. Allen WH, Sedgwick WT. Civics and Health. Athenæum Press; 1909.
5. Henry Ford Health System. Study: snoring may be early sign of future health risks. Henry Ford Health Systems website. https://www.henryford.com/news/2014/06/study-snoring-may-be-early-sign-of-future-health-risks. Published June 17, 2014. Accessed February 23, 2022.
6. Harper RM, Kumar R, Ogren JA, Macey PM. Sleep-disordered breathing: effects on brain structure and function. Respir Physiol Neurobiol. 2013;188(3):383-391.
7. Diiulio R. Sleeping like a baby: Dr Stephen H. Sheldon's pediatric sleep medicine practice. Sleep Review website. https://sleepreviewmag.com/sleep-treatments/therapy-devices/cpap-pap-devices/sleeping-like-a-baby-dr-stephen-h-sheldon-pediatric-sleep-medicine-practice/. Published online November 8, 2013. Accessed February 23, 2022.
8. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117(25):3171-3180.
9. Healthy sleep. Harvard Medical School Division of Sleep Medicine website. https://healthysleep.med.harvard.edu/. Published January 2, 2008. Accessed February 23, 2022.
