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Orofacial Function, Sleep, Airway and Health by Kelley Quolas

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Categories: Sleep Medicine;
Orofacial Function, Sleep, Airway and Health 

by Kelley Quolas

When I began my career in pediatric dentistry in 1996, I had never asked patients if they snored, and had not heard the word airway used in relation to a prevention risk assessment.

Since then, however, dental professionals have learned about the correlation between poor sleep and conditions such as hypertension and cardiovascular concerns, diabetes and stroke. We’re also seeing more evidence related to the relationship between sleep disorders and mental health; for example, an estimated 25%–50% of people with ADHD are not getting restorative sleep.1

Sleep fragmentation—waking up, tossing and turning, snoring, apnea—can interfere with our moods, our behavior and our overall quality of life.

Our responsibility as health care providers includes relaying information about evidence-based practice and encouraging our patients to take responsibility for self-care. As more knowledge and research is released about the correlation between oral dysfunction and airway and sleep, we shouldn’t ignore warning signs that present in our dental chairs.


The screening
The dental team is on the front lines of intervention for sleep- and airway-related problems because dentists and hygienists can look for signs and ask about symptoms and risk factors each time they look in a patient’s mouth.

Many dental practices already include questions like the ones that follow on their patient health history forms. Alternately, you could extract questions from the Pediatric Sleep Questionnaire or the Sleep Disorders Questionnaire and add them to your health history or exam notes.


QUESTIONS FOR ADULT PATIENTS
  • Do you wake up tired or refreshed?
  • Do you wake up to use the restroom or is there a history of bedwetting?
  • When you wake up …
    • Is your mouth dry?
    • Do you have a headache?
    • Does your jaw hurt?
  • Do you snore or breathe heavily during sleep?
  • Is it difficult to fall asleep or stay asleep?
  • Do you have frequent acid reflux?
  • Is your nose frequently congested? Do you suffer from allergies?

QUESTIONS FOR PARENTS OF PEDIATRIC PATIENTS
  • Do you hear the child grind their teeth at night?
  • Do they wake up easily, or is it hard for them to get going in the morning?
  • Is there a history of bedwetting?
  • Do they wake up at night and get out of bed?
  • Can you hear them breathing or snoring when they sleep because their mouth is open?
  • Is it difficult for them to fall asleep or stay asleep?
  • Do they have difficulty paying attention in school or at home?
  • Is their nose frequently congested? Do they suffer from allergies?

A patient who experiences more than one of these symptoms more than once a week and checks “yes” to such questions on their health history would likely benefit from a referral. The same is true if you note any of the anatomic/pathology presentations below, which are often correlated with an unhealthy airway and sleep disorders.
  • Lingual scalloping.
  • Frequent or chronic fractured restorations.
  • Coated tongue.
  • Uncontrolled periodontitis.
  • Red or inflamed oropharyngeal walls and uvula.
  • Linea alba.
  • Little to no space between the tongue and oropharyngeal walls and soft palate.
  • Narrow or vaulted palate.
  • Retronagthic mandible/significant overbite.
  • Relapsed orthodontia.
  • Open bites.
  • Tight and restrictive frenulum attachments.
  • Chronically dry and cracked lips.
  • Chronically enlarged tonsils.
  • Chronic, or a history of, temporomandibular joint disorders.
Chronic, nonrestorative sleep can manifest into behavioral and health concerns for children and adults. Fragmented sleep prevents the body from fully repairing itself and cleaning the brain of plaques,2 which can lead to dementia3 and Alzheimer’s disease.4 It also can interfere with our ability to focus, pay attention and process our emotions.5


The specialists
Once a positive history has been established, it is helpful to have guidance in the referral process. Typically, it’s best to refer out to an orofacial myofunctional therapist initially. Orofacial myofunctional therapists can be viewed as the “quarterbacks” of the care team, because they’ll have a group of providers within their referral network for the patient’s needs.

Alternately, if the patient has had chronic inflamed tonsils noted at each recall/exam, it would warrant a referral directly to an ear, nose and throat specialist (ENT).

Sleep specialist. First, identify a nearby sleep specialist you feel comfortable referring to who can analyze the patient’s sleep quality and make recommendations. At-home sleep testing options also are available.

ENT or allergist. If tonsils are blocking the airway, send the patient to an ENT. Doing this doesn’t necessarily mean surgery will be required; there could be options for management and establishing a baseline. If pathology or anatomical structures impede the patency of the airway, this should be addressed first.

Orofacial myofunctional therapist. Neuromuscular reeducation is an adjunctive therapy, individualized to the patient’s needs, that can help address the root cause of some symptoms of sleep-disordered breathing.6 Orofacial myofunctional therapists, who have postgraduate education and training in this arena, are licensed dental hygienists, speech language pathologists or occupational therapists who’ve trained to screen and assess for barriers to optimal function—tongue and lip ties, mouth breathing, oral habits, etc.—and recommend a therapy plan to manage them.

Therapy sessions involve working toward:
  • Strengthening lips for a lip seal, to encourage nasal breathing.
  • Repetitive lingual movements (exercises): lingual narrowing, widening, cupping, suctioning, focusing on moving the lingual muscles independently from additional muscle recruitment and dissociation of lingual and jaw movement. This is important for TMD cases.
  • Repatterning chewing and swallowing to enhance functional movement and help gastrointestinal motility and digestion.
  • Nasal breathing exercises.
  • Coordination of facial muscles for symmetry.

This is working toward the goal of habituating an ideal oral resting posture: tongue lightly sealed in the palate; teeth resting with ideal freeway space; lips together; nasal breathing. Average patients will be treated for six to 12 months, depending on their needs.

Airway-centric orthodontist. If a patient presents with dental crowding or narrow maxillary and mandibular arches, depending upon the location and the provider, early intervention can be an option even if the patient is younger than 7. There are also options for teenagers and adults to help create more volume for the tongue space and airway.


Conclusion
Dentists and team members need to be aware and knowledgeable when patients ask about airway, tongue posture or sleep concerns. But without organized proper protocols, it can be difficult to find education and support. As a dentist, you should not just consider these questions but research and know the correct answers:
  • What are the markers of sleep-disordered breathing and airway issues, and what do I look for?
  • What referral sources are available to me?
  • Who is my preferred referral team?
  • Is my exam equipped with the tools to extract data for a referral?
  • Is my staff/team trained and educated on these issues?

It’s important to ensure your practice is well equipped to incorporate and have confidence discussing and making recommendations related to sleep and airway issues. Adding this to your knowledge base and referral protocol will be a very rewarding payoff not only to your practice but also to your patients who trust in you.

References
1. Wajszilber, D., Santiseban, J.A., and Gruber, R. “Sleep Disorders in Patients with ADHD: Impact and Management Challenges,” Nature and Science of Sleep, December 2018, Vol. 2018:10, 453–480.
2. Shokri-Kojori, E., Wang, G., Wiers, C., and Volkow, N. “b-Amyloid Accumulation in the Human Brain After One Night of Sleep Deprivation,” PNAS, April 9, 2018, Vol. 115:17, 4483–4488.
3. Sabia, S., Fayosse, A., Dumurgier, J., van Hees, V.T., Paquet, C., Sommerlad, A., Kivimäki, M., Dugravot, A., and Singh-Manoux, A. “Association of Sleep Duration in Middle and Old Age With Incidence of Dementia.” Nat Commun, April 20, 2021; 12(1), 2289.
4. Rwin, M.R., and Vitiello, M.V. “Implications of Sleep Disturbance and Inflammation for Alzheimer’s Disease Dementia.” Lancet Neurol., March 2019; 18(3):296–306.
5. Toschi, N., Passamonti, L., and Bellesi, M., “Sleep Quality Relates to Emotional Reactivity via Intracortical Myelination, “ Sleep, January 21; 44(1).
6. Camacho, M., Cereal, V., Abdullatif, J., Zaghi, S., Ruoff, C., Capasso, R., and Kushida, C., “Myofunctional Therapy To Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis,” Sleep, May 1, 2015; Volume 38:5, pp 669-675

Author Bio
Kelley Quolas Kelley Quolas is a U.S. Army veteran who has been working in pediatric dentistry since 1996. A licensed dental hygienist, she trained with the International Association of Orofacial Myology and is a credentialed qualified orofacial myologist.

Quolas owns a two-location practice in the Phoenix metro area in which dental hygienists and speech language pathologists work together to combat orofacial myofunctional disorders. The practice offers speech therapy, myofunctional therapy and breathing reeducation in Spanish and English for patients of all ages. Website: mymyomyhealth.com.

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