It's only recently that I've begun paying attention to how
people breathe – nose or mouth. In clinical practice I dealt with
the oral effects of mouth breathing, focusing on the increasing
risk of gingivitis and caries. Finding out the cause of their mouth
breathing and counseling them to switch to nose breathing
instead never occurred to me.
Personally, I never considered myself to be a mouth breather,
but waking up with a dry throat in the morning is evidence suggesting
I was in fact a mouth breather! Not anymore. After completing
orofacial myology training and meeting Dr. Steven Sue,
my focus is now on nose breathing.
Try it yourself; check if you are mouth breathing or nose
breathing during the day and at night. A dry mouth in the morning
will answer half the question. Check during the day to see if
your mouth is open. If you lick your lips and need lip balm during
the day, you are very likely a mouth breather.
What's the difference? Turns out, there's a big
difference. My interview with Dr. Sue, a retired
orthodontist from Honolulu, Hawaii, changed
my mind about breathing techniques and he just
might change yours too.
Dr. Sue, when did you begin your focus on nose
Sue: My focus didn't start with nose breathing, but with
non-extraction orthodontics. As an orthodontist, I saw the negative
impact of mouth breathing on early cranio-facial development
in children, leading to narrow palates and malocclusion.
The orthodontic solution to this was extractions, treating the
symptoms and not the cause of the problem. In the early 1970s
I became a strong supporter of non-extraction orthodontics, seeing
that the tongue on the palate when swallowing had the ability
to shape the palate of a growing child. A well-developed
maxilla is essential for the normal cranio-facial development.
The teeth were not too large for the jaws; rather the jaws were
too small for the teeth.
We take swallowing for granted, not really analyzing
the mechanics of it. Tell me what role the
tongue plays in swallowing.
Sue: In normal swallowing, the chewed food is gathered on
the tongue, the tongue is raised for full contact with the roof of
mouth and peristaltic waves are created that sends the bolus of
food straight down the esophagus and into the stomach. When
the tongue is down, forward and thrusting as in mouth breathing,
it does not generate normal peristaltic activity. Instead, trapped air
is taken into the stomach and particles could end up in the trachea
and lungs from the partial closure of the epiglottis.
The most effective way to control the tongue during swallowing
is through nasal breathing. Nasal breathing places the
tongue on the roof of the mouth with a naturally occurring lip
seal and tongue suction.
Is there a physiologic difference between nose
breathing and mouth breathing?
Sue: The nose and the mouth serve very different functions.
Each nostril is innervated by five cranial nerves from
different sides of the brain. Each nostril functions independently
and synergistically in filtering, warming, moisturizing,
dehumidifying, and smelling the air. It's like having two noses
housed in one shelter.
The respiratory system of carbon dioxide and oxygen
exchange occurs in the alveoli of the lungs. Oxygen absorption
depends on the level of carbon dioxide in the lungs. Carbon
dioxide is a vasodilator. Mouth breathing takes in more air, but
also expels more air quickly reducing the carbon dioxide levels
and consequently reducing oxygen absorption. The slower
release of air through the nostrils will keep air in the lungs for a longer period of time, allowing for more oxygen absorption.
When there is proper oxygen-carbon dioxide exchange, the
blood will maintain a balanced pH.
Because the breathing mechanism is situated in the nose and
not in the mouth, the brain of a mouth breather thinks carbon
dioxide is being lost too quickly from the nose and stimulates
the goblet cells to produce mucous to slow the breathing. Thus
the viscous circle of mouth breathing triggers mucous formation,
blocking nasal passages and nose breathing, leading to
more mouth breathing.
Infants breathe through their noses, yet they
have a tongue thrust. You've said that a tongue
thrust and mouth breathing are one in the same.
How can that be?
Sue: Yes, this is true for the first six months of life at which
time infants start to outgrow the tongue thrust and start to place
the tongue on the roof of the mouth at rest and when swallowing
to help shape and develop the cranio-facial structures. This
is done automatically as determined by genetic codes. This relationship
allows a newborn to be an "obligate nose breather"
until the descent of the epiglottis is complete. The early cranial
development is vital for the normal development of the hypothalamus
and pituitary gland.
Infantile tongue thrust serves a useful purpose as it keeps the
tongue from falling back into the throat and helps with swallowing
because the oropharyngeal region is growing at a rapid rate.
"Obligate nose breathing" is not possible in the adult human.
What about the use of pacifiers and sippy cups?
Sue: The rampant use of pacifiers and sippy cups places the
tongue low and forward in a tongue thrust that encourages
mouth breathing. Soon it becomes ingrained, and the habit is
set for a lifetime.
We think of breathing as something restricted to
the nose, mouth and lungs. Which general health
problems are related to incorrect breathing?
Sue: The list is long: snoring, obstructive sleep apnea
(OSA), aerophagia, bloating, burping, flatulence, acid reflux,
fibromyalgia, chronic fatigue syndrome, silent aspiration, pneumonia,
bronchitis, stridor, colitis, chronic cough, hiccups,
asthma, allergic rhinitis, hormonal imbalance, diabetes, bed
wetting, frequent urination at night, malocclusion, deviated
septum, adenoidal face, recessive chin, heartburn, high blood
pressure, stroke, ADHD and SIDS.
Breathing is basic, and every one of our 3 trillion cells needs
oxygen to survive. It's not surprising to see connections between
breathing and the whole body.
How can mouth breathing cause so many problems?
Sue: Man swallows hundreds of times a day and mouth
breathers are swallowing air each time. Eventually, bloating inside
of the stomach puts pressure against the esophageal sphincter and
causes it to weaken and leak, resulting in acid reflux. The continuous
assault of stomach fluid on the pharyngeal lining causes the
throat to lose elasticity and the resulting stiffness will cause the
walls to collapse. This is found in moderate to severe OSA. In
severe apnea, it is more than the tongue that is causing the blockage.
It is the entire pharynx that has collapsed.
Mouth breathers are at risk of aspirating saliva, food and
bacteria into the lungs. This may explain the loss of elasticity in
the lungs of those with Chronic Obstructive Pulmonary Disease
(COPD). Many of the elderly have reverted to mouth breathing
in which pneumonia has been a major cause of death for the
ageing. We are dealing with a myriad of problems that are connected
to each other. Studies show that abnormal swallowing,
aspiration, gastric reflux, and malocclusion occur together yet
are classified as separate diseases. These are not separate diseases.
You've invented a mouthpiece that helps with
nose breathing. Tell me more about Nose
Sue: After many years in orthodontics, I designed a simple
mouthpiece that promotes nasal breathing. By positioning the
tongue to the roof of the mouth, a lip seal is created and you are
encouraged to breathe through the nose.
How does the Nose Breathe mouthpiece work?
Sue: The Nose Breathe mouthpiece stabilizes completed
orthodontic cases by controlling the tongue thrust. It also
teaches children proper swallowing patterns, trains athletes for
endurance and prevents them from overtraining. The Nose
Breathe fits over upper teeth and has a shelf for the tongue. With
the tongue on the shelf, it is in contact with the roof of the
mouth. There is a naturally occurring lip seal and tongue suction
that prevents the tongue from falling into the back of the
throat. The tip of the tongue is just posterior to the incisive
papilla, and not against the anterior teeth. Relaxed, diaphragmatic
breathing is encouraged.
Have you conducted research with your Nose
Sue: The research study, "Snoring Control Using a New
Tongue-Retaining Oral Appliance" by R. Cartwright, et al. was
conducted at Rush University Medical Center in Chicago and
also a private practice in Hawaii concluded that nasal breathing
can effectively reduce snoring and mild sleep apnea. The study
was presented at the Associated Professional Sleep Societies
(APSS) 18th Annual Convention at Philadelphia, June, 2004
and the abstract was published in the Journal of Sleep, Vol. 27,
Are other researchers looking at mouth breathing
in relation to sleep disorders?
Sue: The terms sleep-disordered breathing (SDB) and
obstructive sleep apnea (OSA) imply that breathing disorders
occur only during sleep and that if a person didn't sleep, they
would not have a breathing problem. I suggest it's the breathing
that is the problem and not the sleep.
The majority of sleep researchers overlook daytime breathing
and focus on night time treatments including continuous positive
airway pressure (CPAP), surgeries, drugs and dental appliances.
A recent article in Sleep Review reported that children are
being afflicted with symptoms of sleep apnea and the same treatment
modalities are being recommended for children. Do you
know of anyone who has been weaned off CPAP because it cured
the breathing disorder? Can you imagine what that could mean
to the quality of life to a 10-year-old child on CPAP?
Focusing the research on breathing rather than sleep might
identify problems earlier rather than later. This is a dialogue that
needs to begin. It is my opinion that the initial mouth breathing
had nothing to do with sleep; started during childhood; progressed
in severity to adulthood; and manifested most severely
during sleep; and therefore, preventive and corrective measures
should be started during early childhood development.
Any final words as we wrap up this interview?
Sue: Yes, once people comprehend the significance of nasal
breathing, they will realize the benefits are overwhelming.