by Felix Liao
Beyond the Expertise of Dental Specialists: Dr. A’s CSI
“I was a dentist in my country in South America,” said Dr. A., a slim, trim, thirty-three-year-old stay-at-home mom with three kids. “But I fell in love and married an American and moved to DC.”
Her list of current health concerns included brain fog and moodiness; low energy; depression and feeling sick in an indescribable way; achy head, neck, and shoulder; teeth that were sensitive to cold and sweets; teeth that felt rough and chalky; and a very dry mouth with an acidic taste in the morning.
“That’s a lot to put up with while caring for three kids, Dr. Mom,” I said.
“Yes, and I am worried that I am losing enamel.” (Enamel is the surface layer that makes teeth beautiful and resistant to food abrasion.)
“Yes, you might be losing enamel to acid reflux. Please tell me about your medical history.”
“I had lymphoma four years ago while I was pregnant with my first child. It was treated with chemo and radiation, and I’ve had two more kids since.”
“You’re a walking miracle!”, I replied. “How many mornings a week do you wake up feeling refreshed?”
“I can’t remember a good night’s sleep in more than four years now. I wake up four to eight times every night because of the kids. The youngest is now one and a half.”
“Amazing. I don’t know how you do it.” I added, “Did you have acid reflux before having children?”
“I used to have heartburn four years ago but not now—except when I cheat on my diet.”
“Overall, what would you say is your biggest health issue?”
“I feel I have no energy in my tank to perform my job as a mom.”
“You have a weak chin from a large (5 mm) overjet. Your tongue is like a six-foot tiger inside a three-foot cage formed by your jaws. This leads to a choke zone in your airway. Many of your symptoms are related to airway obstruction, including acid reflux and rough enamel from acid erosion. We’ll need a sleep test to confirm.”
“This is beginning to make sense now,” said Dr. A. “My best friends back in my home country are dying to help me with their specialty. One is an oral surgeon who wants to do surgery, and the other is an orthodontist who wants to do braces for me. I know they mean well, but I’m glad I didn’t let them do their thing on me.”
“A wide-open airway is the real prize in the care of health. Let me share with you what I see in this photo of you standing in profile.
“Your head is forward with your ear opening—the green line—well ahead of your shoulder point, where the yellow line is. That’s why you have head, neck, and shoulder pain.
“Your chin is weak, well behind the upper lip, which drives your tongue into your throat. That makes you susceptible to snoring, teeth grinding, dental sensitivity, jaw-joint clicks/pops/locks, and fatigue.
“Your upper front teeth are naturally straight and your smile is nice, but your upper arch is too narrow for your lower jaw. Moreover, you are likely to have wrinkles around your mouth as you get older because you swallow with your lips pressed together 1,500 times a day.”
“No way are wrinkles around the mouth acceptable! I am glad you tell me that now. What else?”
“How many of these symptoms [in the next slide] do you have?” I asked Dr. A.
“That’s me! We sure didn’t learn this in dental school.”
“You’re not alone, Dr. A. Dental schools train dentists to fix and save teeth, which serves an important basic need. But we’re now in the new era of sleep medicine and oral-systemic links. So welcome to Holistic Mouth Solutions!”
“I can see some hope now.”
Holistic Mouth Bites
Seen through trained eyes, signs of airway struggle often show up in the mouth long before health slides downhill too far.
Posture, profile, tongue position, occlusion, and features on the face and inside the mouth all provide clues to airway struggle in the absence of 3D CT imaging.
A wide-open airway is the real prize in the care of health.
Chapter Six
The Damaging Domino Effect from an Impaired Mouth and Pinched Airway
Underdeveloped faces may indicate a collapse or constriction of the upper pharyngeal airway space.
– G. Dave Singh, DDSc, PhD, BDS,
Epigenetic Orthodontics in Adults(1)
Airway dictates, and the rest of the body accommodates. A human body can go for days without eating, but a brain does not last more than four minutes without oxygen. Oxygen on demand is a prerequisite for health and well-being. Just watch a baby sleep after a good feeding.
A good night’s sleep is built on the foundation of a wide-open airway without choke points. Sleeping with a tiger tongue crowding the airway results in oxygen interruption during sleep threatens survival and elicits an involuntary response, which can include jaw clenching, teeth grinding, tossing and turning, elbowing and kicking, chest heaving, waking up with a gasp, bladder urgency, and a racing heart. You may or may not remember your airway struggle during sleep, but you will feel it the next morning in your mind, body, and mouth.
Repeating this pattern night after night will eventually lead to degeneration and health troubles. An impaired mouth structure is the first piece to fall in that domino. Let’s take a closer look at the tongue inside the “three-foot cage” as it relates to the airway.
How a Tongue Becomes a Life-Threatening Tiger inside an Impaired Mouth
The tongue is fully functional at birth for feeding. This is a survival necessity. From then on, daily multitasking keeps the tongue fit through talking, eating, and swallowing saliva 1,200 times a day. So unlike the jaws, the tongue is never underdeveloped.
By contrast, the jaws and face take fifteen to eighteen years to reach final adult size and form. This is a long time in which craniofacial development can go wrong, including tongue-tie, a pathological swallow pattern (from bottle-feeding and long-term pacifier use), nutritional excess (junk foods) and deficiency (such as minerals for building bone), and habitual mouth breathing from chronic stuffy nose, among others. Many adults with sleep apnea, snoring, teeth grinding, and mood disorders have these signs and symptoms.
Anatomically, the back of the mouth merges with the upper airway— the pharynx that is between the back end of the nasal passage and the trachea (windpipe). In the slide below, Zone 1 is the nasal cavity while Zone 4 is the oral cavity, where the tongue belongs.
The oral pharynx is the space behind the tongue (Zone 3) while the nasal pharynx is the space (Zone 2) behind the soft palate at the back end of the upper jaw.
In a Holistic Mouth, all four zones are wide open for uninterrupted oxygen delivery 24/7. So what might close them?
Structural defects have been linked to bony and tissue abnormalities, reports a 1997 study from Japan comparing the upper airway of sleep apnea and normal patients.(2) These load the pharynx and predispose it to airflow obstruction during sleep. These abnormalities can include:
An oversized tongue (macroglossia)
An undersized space (“three-foot cage”) for the tongue
Obesity around the jaws and neck
Any combination of the above
This is worth repeating: the tongue belongs in the mouth, not the airway. When the tongue invades the airway and cuts oxygen delivery, the body reacts with distress—as if it is confronting a six-foot tiger threatening its life. Whether severe or mild, oxygen deficiency sets off a chain reaction throughout the body.
In my experience, adults with sleep apnea and teeth grinding frequently have a pinched airway inside an impaired mouth, and vice versa. Simply put:
Impaired Mouth = Pinched Airway = Medical, Dental, Mood Symptoms from Impaired Mouth Domino
There is one important exception to the “normal size 6” tongue: swelling from hypothyroid (low) function, which is extremely common in the U.S.
A Super-Sized Tongue Is Linked to Hypothyroid, Pain, and Inflammation
In some cases, the tongue
may be swollen, too large in and of itself. This may be caused by poor digestion or fluid retention, but among my patients, the most usual cause is hypothyroidism. Common signs of low thyroid function include cold hands and feet, a thin or missing outer third of the eyebrows, excess weight, thinning hair, and a hoarse voice.
Thyroid function is critically connected to both oral and total health. A 2014 study in the Journal of Oral and Maxillofacial Pathology reported: “The oral cavity is adversely affected by either an excess or deficiency of thyroid hormone. Childhood hypothyroidism known as cretinism is characterized by thick lips, large protruding tongue (macroglossia), malocclusion, and delayed eruption of teeth.”(3)
In my experience, patients with thyroid disorders often have adrenal exhaustion from restless sleep night after night. They also have tighter muscles, tendons, and ligaments and more aches and pains. “Muscular dysfunction and tension resulting from hypothyroidism were major underlying factors in the development of TMJ syndrome … due to the increased incidence of jaw muscle spasm, muscular tension, and pain that are often associated with hypothyroidism,” writes Dr. Mark Starr in Hypothyroidism Type 2: The Epidemic.(4)
This means hypothyroid patients can expect more creaky messages from their mouth and body when they start oral-appliance therapy. That’s why, when I see a swollen tongue, I routinely refer my patient for a medical evaluation to rule out low thyroid function and to adjust the supplements as needed under medical supervision. This is WholeHealth integration.
Hypothyroid Tongue Test
Here’s a simple test to see if you may be suffering from low thyroid: Stick out your tongue past your lips and check for space between the corners of your mouth and the side of your tongue. Absence of space suggests hypothyroidism -- I learned this from Dr. Jorge D. Flechas, MD, of Hendersonville, North Carolina.
Inflammation goes down with treatment of hypothyroidism. For instance, a 2015 Brazilian study “observed significant changes in the inflammatory profile in hypothyroid patients under treatment, with reduction of pro-inflammatory cytokines and elevation of anti-inflammatory cytokine. In these patients, a decrease in low-grade chronic inflammation may have clinical relevance due to the known connection between chronic inflammation, atherosclerosis, and cardiovascular events.”(5)
Treating hypothyroid properly works synergistically with oral appliances to reduce pain, fatigue, and heart disease. This is the WholeHealth part of Holistic Mouth Solutions.
Holistic Mouth Bites
Airway dictates, and the rest of the body accommodates. This is “Rule 1” in how the body works.
The tongue belongs in the mouth, not the airway. When the tongue occupies the oral airway, the body reacts as if it is confronting a six-foot tiger threatening its life, setting off a chain reaction throughout the body.
Low thyroid function—hypothyroidism—is a very common cause of a super-sized tongue. Having hypothyroid properly treated works synergistically with oral appliances to reduce pain, fatigue, and heart disease.
Chapter Seven
A Deeper inside Look at Sleep Apnea
Ninety-five percent of the Americans with sleep apnea do not know they have sleep apnea and consequently face cardiovascular complications and sudden death.
– William C. Dement, MD(1)
Deep sleep can raise the dead-tired, provided the tongue is not in the airway. The problem: most patients with Impaired Mouth do not know that they sleep with a pinched airway that disrupts their sleep. “Suddenly, I am not half the man I used to be”, as the Beatles’ song Yesterday goes, can simply be a reflection of Impaired Mouth Syndrome.
Sleep bruxing in the slide above was not in Dr. Dement’s paper, but is added by the author as a proposal.
Obstructive sleep apnea (OSA) is characterized by the collapse of the airway during sleep. Simply, the muscles in the back of the throat relax too much, making normal breathing impossible. The ensuing oxygen deprivation contributes to a long list of mind, body, and mouth symptoms, including teeth grinding and its related complications.
This should be of interest to all patients, health professionals, health insurers, and employers alike because it harms health and raises costs. A 1999 University of Washington study found that medical costs are about two times higher for patients with undiagnosed sleep apnea compared with age- and gender-matched individuals.(2)
In my experience, many dental issues are also the fallout of OSA, including teeth grinding, gum recession, dental sensitivity, bone loss that eventually leads to failed dental work, many root canals, and fractured teeth that require extraction and implants. (Book 2 of the Holistic Mouth Solutions series will cover teeth grinding in depth.)
Deadly OSA Is STILL Undetected 75 Percent of the Time
Sleep-disordered breathing (SDB) is the medical term for abnormal breathing patterns during sleep, and it is “associated with considerable morbidity,” according to the American Academy of Sleep Medicine.(3) OSA is a common form of SDB.
Daytime sleepiness is a cardinal feature of sleep apnea. Others include waking up tired, jaw clenching, and teeth grinding, which is now called sleep bruxism in sleep medicine.
While 3D-CT imaging can raise clinical suspicion and provide objective evidence, it cannot be used alone to diagnose OSA. Only a doctor trained in sleep medicine can diagnose OSA. An overnight sleep test collects data on brain waves, heart rate, muscle activity (or lack thereof), oxygen levels, and breathing.(4)
A 2002 study in The Lancet stated: “OSA can be diagnosed on the basis of characteristic history (snoring, daytime sleepiness) and physical examination (increased neck circumference), but overnight polysomnography [commonly known as a sleep test] is needed to confirm presence of the disorder.”(5)
Yet OSA—and SDB in general—still goes largely undiagnosed. The prevalence is high among men and is much higher than previously suspected among women. A 1993 New England Journal of Medicine study reported “9 percent of middle-aged women and 24 percent of middle-aged men have undiagnosed SDB.”(6)
Fifteen years later, the same researcher found that 75 percent of severe sleep apnea cases had still gone undetected.(7)
How Holistic Mouth Doctors Can Help Screen OSA Cases
The health problems linked with OSA are severe and widespread. Experts estimate that as many as one in four American adults could benefit from a sleep evaluation. I believe every medical and dental patient deserves a screening to rule out airway obstruction as a source of presenting symptoms.
A much overlooked solution is a Holistic Mouth that can support deep sleep and natural recovery. Redeveloping the jaws with the right type of oral appliances can provide just that, bringing the body back to life with a wider airway and deeper sleep.
Given how widespread OSA is—and the prominent role of the mouth in OSA—dentists trained as Holistic Mouth doctors are in a good position to recognize orofacial signs of an impaired mouth and obstructed airway, to screen for OSA (and thereby refer affected patients for sleep tests), and to provide oral-appliance therapy where indicated.
A Holistic Mouth checkup can serve as a valuable screening opportunity to catch this costly condition early on. After all, most of the leading causes of OSA start in the mouth, and many signs of “six-foot tiger, three-foot cage” are readily seen during a dental exam:
A lower jaw that is short compared with the upper jaw (retrognathia)
Certain shapes of the palate or airway that cause the airway to be narrower or collapse more easily
A large neck—seventeen inches or more in men, sixteen inches or more in women
A large tongue that can fall back and block the airway
Obesity
Large tonsils and adenoids in children that can block the airway(8)
The tongue is the big obstructor in OSA. Freeing the airway of a tongue obstruction using oral appliances as part of an overall wellness program can improve sleep, restore energy, and upgrade life quality for patients, as we shall see in the case studies ahead.
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nbsp; Holistic Mouth Bites
Snoring, sleep apnea, and teeth grinding all have an impaired mouth as their anatomical source.
An impaired mouth and pinched airway are the anatomical roots of OSA, with the tongue as the big obstructer. Oxygen deprivation contributes to a long list of mind, body, and mouth symptoms.
A Holistic Mouth checkup can serve as a valuable screening opportunity to catch this costly condition early on. Dentists trained in Holistic Mouth Solutions can help free the airway of a tongue obstruction to help improve sleep, restore energy, and upgrade life quality for patients.
Chapter Eight
Resolving High Blood Pressure without Medication: Case Study
Half of all OSA patients have high blood pressure.(1) Why? While salt is a well-known culprit, an impaired mouth’s contribution to high blood pressure through OSA is virtually unknown. Here is a case of how blood pressure can be lowered when an impaired mouth is treated with oral appliances.
B.N. was a forty-six-year-old mom with six kids. She had a family history of heart disease and sought out Holistic Mouth care because:
She had a medical diagnosis of mild obstructive sleep apnea (OSA). Her sleep test showed an AHI of 11, with very loud snoring 50.2 percent of the time.
She had woken up tired three to four mornings a week “for as long as I can remember.”
Her medical doctor had recommended continuous positive airway pressure (CPAP), but she had found it impossible to sleep with that mask.
She had persistent pain across the top of her shoulders and lower back on and off for fifteen years.
She had high blood pressure and had been on medication for nine years. Her blood pressure was 120/80 mm Hg with medication, and 140/95 without. (Normal is 120/80 more or less, depending on your doctor’s belief and criteria.)