Six-Foot Tiger, Three-Foot Cage

by Felix Liao

  On the color scale, white means a uniformly wide airway with a low risk of airway collapse/obstruction; red means a high risk of collapse while black is off-the-chart dangerous.

  Holistic Mouth Bites

  Science has confirmed the oral-systemic links—an ever-increasing number of mouth-body connections that join the dental and medical spheres.

  Oral-systemic links are two-way streets. The whole can affect the mouth, and the mouth can have systemic-wide ripple effects. Thus medical symptoms can have oral sources.

  If the airway behind the soft palate and tongue is narrow, the risk of airway collapse goes up. Such oxygen deficiency leads to and magnifies a wide variety of health problems.

  Chapter Four

  Saving His Life & Her Sanity:

  “It’s Like He’s Strangling in His Sleep” (Case Study)

  My husband has a sleep pattern that wakes him up from a seemingly sound sleep every twenty minutes almost in a panic. It’s like he is strangling … and it’s concerning because its affecting both of our lives and how we feel the next day. We are more tired.

  – Mrs. D.E.

  There are all kinds of people but only two kinds of mouths. A Holistic Mouth promotes total health and facial radiance while an impaired mouth starts a cascade of medical, dental, mood, and financial troubles. In my experience, the troublemaker is very often an underdeveloped set of jaws that cannot accommodate the tongue between them.

  Saving a Marriage While Saving a Life: The Case of D.E.

  D.E., a forty-seven-year old lawyer, was referred to me by his nutritionist. His presenting health complaints included:

  Pain in low back [L4/5] and mid-upper back, poor digestion and bloating, frequent sinus infections and bouts of congestion, heart arrhythmia sometimes, and a mouth that had always felt too small for his tongue.

  It’s worth noting that D.E.’s wife was concerned about his troubled breathing and her own sleep while D.E.’s focus was on his pain.

  When he opened his mouth, I saw spotlessly clean teeth and gums. D.E. commented, “My dentists have never found anything wrong with me. But my nutritionist thinks my mouth may be the cause of my remaining health issues.”

  “Besides the symptoms you’ve mentioned, how is your day-to-day stress level on a scale of zero to ten?”

  “I’d say six.”

  “How’s your weight in relation to where you’d like to be?”

  “I suffer from living the good life, with good wine and all the foods that go with it. But I work out regularly to keep the weight at bay.”

  “How many days a week do you wake up feeling refreshed?”

  “Two. Maybe one.”

  “That can be a clue pointing to an impaired mouth. When was the last time you had a medical and dental checkup?”

  “I see a chiropractor every two weeks to avoid medication and surgery, and I have my dental checkup and cleaning every six months without fail, so there’s not much for them to do.”

  “What do they tell you about your symptoms?”

  “Not much, other than come back every six months.”

  “Anything else you want to add?”

  “I believe in the power of essential oils, alkaline water, nutrition, and massage. I do them all, but I seem to have hit a wall in my health quest.”

  “OK. Let’s do our CSI: chair-side investigation. We’ll start by connecting your posture with your bite, which can have a role in your chronic pain.”

  The Importance of a Holistic Mouth Checkup: Is Your Mouth Hurting Your Health?

  Imagine driving across the country in a high-end car with defective steering. The tires will wear out sooner, the trip will likely be unpleasant and costly, and the destination may be beyond reach.

  The same is true with going through life with an impaired mouth, which “is much more than healthy teeth,” as US Surgeon General Dr. David Satcher put it in Oral Health in America.(1) D.E.’s case shows what can happen to overall health when the mouth is structurally impaired, even if the teeth and gums are fine.

  Holistic Mouth checkup for D.E. revealed a significantly impaired mouth with:

  A forward neck and backward head tilt that is typical of people with narrow airways

  Habitual mouth breathing from chronically stuffy nose

  Malocclusion with misaligned upper and lower dental midlines, which is a frequent source of neck, shoulder, and back pain

  A deep overbite (5 mm vs. the ideal of 1 to 2 mm) and retruded jaws, which combine to offer the normal size 6 tongue with a size 3 space

  Extraction of two upper premolars for orthodontics in high school, which had reduced his arch length and the oral volume for his tongue

  Tongue-tie anchoring his tongue to the floor of the mouth instead of its roof—a recipe for a deficient upper jaw and crowded teeth.(2) A tongue-tie is a short and tight ligament under the tongue that limits its movements and confines it to the floor of the mouth, which contributes to impaired mouth development— see chapter 13.

  An abnormal swallowing pattern involving a gurgling sound, coupled with forceful contractions of muscles around his mouth (In my opinion, this abnormal swallowing had contributed to the relapse of prior orthodontic treatment.)

  A very narrow airway (in the orange-red zone of color scale), highly susceptible to sleep apnea (3)

  The mouth, in side view, is convex and full when an airway is wide, which I see only once in a blue moon. In profile, D.E.’s upper lip was flat.

  Now look at the young lady in the image below, and imagine squashing her upper and lower jaw and its contents into her face, toward the back of the head. That is exactly how an impaired mouth pinches the airway.

  On the color scale, white end means low risk of airway collapse, red means a high risk, and black is off-the-chart dangerous.

  What D.E.’s Sleep Test Revealed and What Can Be Done

  Suspecting a pinched airway inside an impaired mouth, I sent D.E. for a sleep test, which confirmed severe obstructive sleep apnea (OSA), a reduction or stoppage of breathing during sleep despite efforts to breathe, and a corresponding drop in oxygen supply.(4)

  To experience an apnea event, try this: Inhale and exhale normally, then cover your nose and mouth with your hands so no air gets in or out as you count “one, one thousand; two, one thousand” until you get to eleven. Now lift your hand. Aren’t you glad to get that breath?

  D.E.’s sleep test showed that, on average, his breathing suffered thirty-seven times an hour from a combination of apnea or his blood oxygen dropping by 4 percent or more (hypopnea)! This number—the apnea-hypopnea index (AHI)—is often used as a benchmark for OSA. Here’s how the results break down, according to the Cleveland Clinic’s online medical reference:

  Mild OSA: AHI of 5–15. Involuntary sleepiness during activities that require little attention, such as watching TV or reading

  Moderate OSA: AHI of 15–30. Involuntary sleepiness during activities that require some attention, such as meetings or presentations

  Severe OSA: AHI of more than 30. Involuntary sleepiness during activities that require more active attention, such as talking or driving(5)

  After reviewing his options with his sleep-test doctor, D.E. chose oral-appliance therapy over CPAP, which is a mask worn over the face that delivers air past the airway blockage under positive pressure. Besides, his chief complaint was back pain, and oral appliance can fix pain.

  “The three-foot cage makes sense now,” D.E. said. He pointed to the orange bulge on his CT image above. “That whole thing is the tongue? I had no idea it’s that huge! It’s a wonder I’m alive and can get any work done.”

  “It is indeed. And there are more health hazards ahead if it’s left untreated.”

  “That’s why I’m here. Is there any hope for me?”

  “Yes, thanks to the new science of epigenetics and the new breed of oral appliances that can switch on your genes to increase your jaw size as if you were a teenager again to regrow and realign your jaws to fix pain na
turally.”

  “Sounds good. What else do I need to know?”

  “In my practice, oral appliances are just one part of WholeHealth-oriented Holistic Mouth Solutions. In your case, we’d first have you do the oral-appliance therapy plus myofunctional therapy (chapter 13) to retrain your mouth to swallow correctly—after your tongue-tie is released and your diet tweaked to minimize stuffy nose.

  “In phase 2, you’ll wear orthodontics to bring your teeth back into a stable peak-to-valley bite. Finally, we’ll do some restorative dentistry to replace those two upper teeth that were extracted for braces.”

  “Now I see why my nutritionist sent me here. I’m in. Let’s do it.”

  “You should know that phase 1 takes about a year in mild cases. In severe cases like yours, two or more years is common. Phase 2 can take sixteen to twenty-four months, depending on case complexity and patient compliance.”

  “I can’t wait to get started.”

  Alternative to CPAP’s Life Sentence: D.E.’s Oral-Appliance Therapy

  Oral appliances are custom-made mouthpieces worn over the teeth to free the body from the tyranny of an impaired mouth with its bad bite and pinched airway. They come in many types. D.E.’s set of oral appliances was designed to relieve his whole body of his bad bite and to widen his airway during sleep.

  “Huge Improvement” That Typical Doctors and Health Professionals Can’t Touch

  D.E.’s symptoms improved quickly after starting oral-appliance therapy. He faithfully followed my prescribed Holistic Mouth Solutions, which included acupuncture and osteopathic care, going to bed by 11:00 p.m., and continuing his chiropractic visits and sound nutrition.

  Two months after we began, his airway had improved by 56 percent. At three and a half months, he had this to say:

  I came to Dr. Liao suffering from back pain for most of my life. I have seen chiropractic doctors and nutritionists but never saw any real relief. Now, after wearing an oral appliance, my airway has opened up 70% and my low back pain is almost nonexistent.

  After fifteen months, he reported that his blood pressure had “gone down quite a bit: from 140/90 to 110/60 now. So it’s been a huge improvement—I feel so much calmer.”

  I find that unexpected symptom improvements are common in patients undergoing oral-appliance therapy. It had not even occurred to D.E. that he had lived with anxiety until it went away with oral appliances that opened his airway as he slept.

  Two years later, “Blood pressure, weight, wellness, ability, breathing all good,” he reported. “Breathing is easier, and tongue fits better into upper mouth. And by the way, I won the tennis tournament at my club without having to use knee and back braces.”

  D.E.’s subjective improvement was documented in his systemic evaluations as well. One month after starting oral-appliance therapy, D.E.’s nutritional therapist sent his EAV (electro-acupuncture according to Voll) report (see below), showing that the body burden was much less. (In these images, green is good; red and yellow are not.)

  Ten months later, another report showed that D.E. was systemically “cleaner” and that his body had regained the ability to respond to nutritional therapy quickly.

  Oral-appliance therapy helped make this progress possible by turning D.E.’s impaired mouth around toward a Holistic Mouth.

  Holistic Mouth Bites

  A clean dental bill of health does not mean the mouth is trouble-free. Evaluating the state of the airway and seeing the size 6 tiger tongue inside a size 3 mouth can provide clues.

  Living with an impaired mouth amounts to driving a top-end car with a broken wheel. The journey is bumpier and costlier, and the quest for health feels beyond reach.

  An impaired mouth is no longer a life sentence. Wearing oral appliances to sleep is simple, and positive outcomes are predictable with patient cooperation.

  Chapter Five

  CSI for Your Mouth: Revealing the Secrets of an Impaired Mouth Detective

  Awareness is prerequisite to all acceptable changes of theory.

  – Thomas S. Kuhn,

  The Structure of Scientific Revolutions(1)

  Sleeping with a tongue that closes your airway and threatens your life amounts to a dry form of waterboarding night after night. Signs of airway struggle can and often do show up in the mouth long before health slides downhill too far.

  “CSI” in this book stands for “chair-side investigation”, as mentioned earlier. With one look at a patient’s face, I can often tell if they are at risk for an obstructed airway. You, too, can acquire Sherlock Holmes’ eyes for recognizing an impaired mouth.

  Postural Clues Pointing to a Pinched Airway

  The first clue to an impaired mouth can be the posture of the head and neck in profile. In response to a pinched airway, the neck will extend forward, and the head may tilt backward in an effort to get more air. If you were to lie down in this posture, you’d be in the recommended posture for receiving CPR—neck extended, head back, and chin up.

  This postural compensation eventually leads to a humped upper back and pain and/or stiffness in the neck and shoulders.

  Liao’s Sign: CSI Clue #1

  A flat or curled upper lip in profile view is such a regular feature in patients with an impaired mouth that I gave it a name: Liao’s Sign.

  Liao’s Sign is a “rule of thumb” facial indicator of a retruded upper jaw that characterizes an impaired mouth. Retrusion is the opposite of protrusion. A retruded maxilla frequently results in a narrower airway behind the soft palate.

  A positive Liao’s Sign implicates a less-than-optimal airway until proven otherwise, yet the absence of Liao’s Sign does not mean all is well. A non-retruded maxilla can still be too narrow, thus contributing to a three-foot cage.

  Friedman Tongue Position: CSI Clue #2

  For predicting OSA in the absence of a CT scan, the position of the tongue at rest is a useful indicator. The Friedman Tongue Position (FTP) score is done with the mouth open and the tongue inside the lower dental arch.

  The less you can see of the uvula (the tissue that hangs at the back of your mouth, above your throat), tonsils, and soft palate, the higher the risk of severe OSA, according to a 2011 Spanish study(2).

  Matching Wear Facets: CSI Clue #3

  Matching wear facets between upper and lower teeth suggest teeth grinding, which in turn is connected to airway distress during sleep, as we shall see in Book 2.

  Wear facets in molars tend to break teeth and loosen dental work while wear facets in front teeth can disfigure a pleasing smile. A sure way to look older than your age is to grind short your smile teeth. The next slide shows a normal bite and an unworn set of front teeth.

  Malocclusion in Any Form: CSI Clue #4

  In general, teeth crowding is a sign of malocclusion (bad bite), which can come from deficient jaws, which in turn is a frequent red flag for airway issues.

  Straight teeth do not necessarily mean absence of malocclusion. For instance, a retruded maxilla with orthodontically straightened teeth is still a health liability.

  Malocclusion comes in many variations. A crossbite means one or more lower teeth lie outside the upper arch with teeth close together. Normally, the upper jaw should be wider than the lower. Crossbite suggests that the upper jaw is deficient in size or retruded in position.

  Excessive Overbite and Overjet: CSI Clue #5

  Two frequently used terms in malocclusion are overbite and overjet. “Overbite” refers to the vertical overlap between the upper and lower front teeth while “overjet” refers to the horizontal distance between upper and lower front teeth. In both cases, the ideal measure is 1 to 2 mm. Anything greater than this may indicate structural deficiency or imbalance.

  A deep overbite means that the ceiling of the tongue’s habitat is very low, which implicates a pinched airway. Facially, a pronounced groove between the chin and the lower lip suggests a deep overbite.

  The larger the overjet (“underbite”), the closer the lower jaw is to the throat, and the
more the tongue is in the airway.

  Weak chin is the surface sign of a large overjet and a retruded lower jaw below the surface dragging the tongue into the airway. Research from Japan has shown that “overjet was associated with the severity of obstructive sleep apnea syndrome in non-obese patients.”(3)

  Other Common Orofacial Clues to an Impaired Mouth

  Other orofacial (mouth and face) signs indicating that all is not well with the mouth and airway can include:

  Tooth prints on the sides of the tongue—medically called crenation—can mean poorer sleep. Research has found tongue scalloping to be predictive of sleep pathology.

  Abfractions are notches of missing tooth structure at the gum line, which science has confirmed may be caused by teeth grinding. (4), (5) Abfractions are often very sensitive to cold and brushing.

  Visible Sclera: Sclera is the white part of the eyeball. When sclera is visible between the lower eyelids and iris (the colored part of the eyes), it suggests a deficient maxilla (upper jaw) because the floor of the eyes is the roof of the maxilla.

  Narrow nostrils and a small mouth with dry or chapped lips indicate chronic mouth breathing, which can cause abnormal craniofacial development. Both are visible in the image directly above.

  Tori are bony outgrowths on the roof of the mouth, the tongue side of the lower jaw, or the cheek side of either jaw. They are the jawbone’s response to excessive pressure from jaw clenching or teeth grinding. “In adults, it is likely that palatal and mandibular tori are manifestations of undiagnosed sleep-disordered breathing.”(6)

  Facial creases and wrinkles around the mouth are more than a mere cosmetic issue. These deep creases and wrinkles come from a lifetime of improper swallowing. Keep in mind that you swallow a minimum of 1,000 times a day! Such improper swallowing can carve creases and etch wrinkles around the mouth over a lifetime.