AirwayCentric Dentistry
Early childhood intervention to open narrow airways improves development
Michael Gelb, DDS, MS
I recently heard from a good friend and dental colleague that some dentists refer to airway dentistry as a trend and dismiss what is actually a vital transformation of the profession. The reality is that airway is something that all dentists deal with every day. However, some are unknowingly closing the airway with treatments such as nightguards that retrude the mandible and excessive interproximal reduction or extractions in combination with orthodontics, whereas many others are becoming aware of how to open and grow the airway. Although sleep-related breathing disorders (SRBDs) are typically managed by sleep doctors, the airway itself is best managed by the dental profession. A patent airway trumps diet and exercise as a pillar of health, and when dentists deliver treatments that improve airway function, it can enable patients to begin the path to wellness.
During the last 300 years, our faces have narrowed and lengthened. In his latest book, Breath: The New Science of a Lost Art, James Nestor describes the evidence from around the world that confirms this epigenetic phenomenon in ancestral medicine. In addition, Weston Price, DDS, documented the changes that occurred after the introduction of a modern industrialized diet, which included tooth crowding, narrowed arches, and facial changes, and other researchers have published similar findings.1-4 As our brains grew bigger, our midfaces receded and retruded significantly when compared with those of early Homo sapiens. As the foundation in the maxilla and mandible collapsed, tooth crowding increased. Although the evidence shows that our ancestors had broad arches and straight teeth with no caries, today, there is rarely room in the arches for all 32 teeth, and third molar extractions are frequently required. As a result of these evolutionary facial changes, our airways have narrowed. Narrow maxillas and high vaulted palates are associated with SRBDs in both children and adults. Furthermore, a smaller maxilla in combination with a retrognathic mandible reduces the available space for the tongue, which forces it back and into the critical airway space.
According to Christian Guilleminault, MD, all children who are born premature are mouth breathers5 who cannot suck, swallow, and breathe appropriately, which makes it difficult for them to breastfeed. When prematurely born or other babies who exhibit mouth breathing become older, they often work with myofunctional therapists and then occupational therapists and speech therapists to improve nasal breathing and tongue function. Intervention as early as birth with frenectomy, when indicated, and at 30 months with myofunctional growth guides can begin to improve the craniofacial respiratory complex. One of the goals of early childhood intervention is to help these children become obligate nasal breathers. Because growth hormone is released during deep sleep, ideal development of the face and brain is dependent on proper resting oral posture and nasal breathing.
With smaller jaws and narrowed airways, mouth breathing children often develop snoring, upper airway resistance, flow limitation, and obstructive sleep apnea. Bonuck,6 Gozal,7 and Chervin8 have shown the impact that this has on the prefrontal cortex of the developing brain. According to Sharon Moore, author of Sleep Wrecked Kids,9 children who sleep poorly due to airway issues have been shown to exhibit 40% to 100% increases in ADHD, anxiety, depression, peer-to-peer issues, withdrawal, and aggressive behavior. However, early intervention restores normal sleep and allows 50% of these children to stop taking all of their medications.
Although retractive techniques are still pervasive in the curriculums of many orthodontic programs, a paradigm shift from merely aligning the teeth to opening the airway is helping to ensure ideal growth and development. For children who are mouth breathing, intervention must occur as early as birth with frenectomy and then again at 30 months. By age 7, the brain is largely developed, and at that time, the orthodontist is entering too late. Many pediatric dentists, general dentists, and orthodontists are picking up the torch regarding early intervention, but others are dragging their feet. With at-home sleep tests and cone-beam computed tomography machines with large fields of view to visualize the airway, nose, and narrowed palates, today, it's just as easy to open the airway as it is to close it. Who do you want to be?
About the Author
Michael Gelb, DDS, MS, is a TMJ and sleep dentistry specialist with practices in both New York City and White Plains, New York. He is the co-author of GASP: Airway Health-The Hidden Path to Wellness and the co-founder of both The Foundation for Airway Health and The American Academy of Physiological Medicine and Dentistry.
References
1. Price WA. Nutrition and Physical Degeneration. 8th ed. Price-Pottinger Nutrition Foundation; 2009.
2. Lieberman DE. The Evolution of the Human Head. Belknap Press; 2011.
3. Lewis, KR. Our skulls are out-evolving us. OneZero website. https://onezero.medium.com/our-skulls-are-out-evolving-us-and-that-could-mean-a-public-health-crisis-f950faed696d. Published September 19, 2019. Accessed January 30, 2023.
4. Corruccini RS. How Anthropology Informs the Orthodontic Diagnosis of Malocclusion's Causes. EdwinMellen Press; 1999.
5. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2013;3:184.
6. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857-e865.
7. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3):616-620.
8. Yu PK, Radcliffe J, Taylor HG, et al. Neurobehavioral morbidity of pediatric mild sleep-disordered breathing and obstructive sleep apnea. Sleep. 2022;45(5):zsac035.
9. Moore S. Sleep Wrecked Kids. Morgan James Publishing; 2019.
