Airway Dentistry

What Is Sleep Disordered Breathing?

Sleep disordered breathing describes a group of sleep breathing issues involving:

1. Abnormal respiratory patterns such as loud or chronic snoring, apnea, and/or hypopneas
2. Insufficient ventilation during sleep, stemming from systemic disease or anatomical issues which may cause narrowing of the breathing passages

An apnea is when a person stops breathing for at least 10 seconds, before “waking up” to take a breath. A hypopnea is when a person’s breathing becomes shallow for 10 seconds or more. Their blood levels of oxygen may drop, but they don’t actually stop breathing completely.

Experts agree that things like mouth breathing, light snoring, noisy or effortful breathing, fitful sleep, multiple awakenings at night, insomnia, bed wetting, etc. are also signs that a person may have a sleep breathing problem.

When breathing is impaired, you may not be getting sufficient oxygen to your brain and tissues while you sleep, or your body may be making compensations night after night to open the airway, which can leave you exhausted in the morning. This nightly battle may manifest in many different health concerns, such as high blood pressure, migraines, gastrointestinal disorders, autoimmune diseases, and depression and anxiety to name a few, which are often overlooked as having a basis in a lack of quality sleep.

Causes And Diagnosis

There are many reasons a person may develop sleep apnea, and similar sleep disorders, at any stage of life. Some of the most common are weight gain, large tonsils or adenoids, respiratory problems like asthma, allergies, COPD, nasal obstruction, a narrow palate leading to reduced room for the tongue and smaller nasal passages, and loss of tone in the airway and tongue muscles.

If you or your doctor suspect that you have a sleep breathing issue, he or she may order you a sleep study, which can either be done at home (Home Sleep Test), or in a laboratory overnight (Polysomnogram). If you, or your doctor, aren’t totally convinced enough to order a test for you or a family member, you can also track your sleep at home with free Apps like SnoreLab, or with devices like the Apple Watch or FitBit. Videoing a sleeping child or spouse at night can also be very revealing. This data can give you and your doctor more information to see if a more in-depth test is needed.

Sleep studies, particularly those done in a lab overnight, will tell you if you are suffering from one of many sleep disorders. Some common diagnoses patients receive are:

1. Sleep Apnea: Characterized by loud snoring, choking noises, and pauses in breathing leading to oxygen deprivation. A patient will be diagnoses as Mild, Moderate or Severe, depending on how many apneas and hypopneas they have throughout the night. This score is called the Apnea Hypopnea Index (AHI)
2. Upper Airway Resistance Syndrome (UARS): Often called the “young, fit, female disease,” this sleep disorder is characterized by the narrowing of the airway, not a cessation in breathing like in sleep apnea. This leads to poor sleep and daytime fatigue because the body compensates to open up the airway all night. It is harder to diagnose, as traditional sleep studies look for apneas and hypopneas, which these patients might not have. They also tend to be young and of healthy weight, so doctors might overlook a sleep disorder as the main cause of ailments such as jaw and facial pain, headache/migraine, IBS, chronic fatigue, depression and anxiety, etc.
3. Insomnia: Described as problems falling or staying asleep. This can be short-term, due to major life events or stressors, or a more chronic form, which is less common, but can be seen in conjunction with UARS.

Restless Leg Syndrome (RLS), Narcolepsy, and REM Sleep Behavior Disorder are also common diagnoses from a sleep study.

If you suspect that you or a family member may be experiencing a sleep disorder, we encourage you to discuss your concerns with your physician and with Dr. Robert J. Williams, DDS, or Dr. Robert C. Williams, DDS, FAGD, at your next dental visit. Our doctors understand the important connection between oral health and sleep health and can help identify signs that may warrant further evaluation. We are fortunate to have access to excellent sleep medicine resources throughout Northern California, including the renowned Stanford Sleep Medicine Center, and can help guide you toward appropriate care when needed.

Signs In The Mouth

Over the last several years, a growing body of research has demonstrated that many dental concerns may have airway-related issues as an underlying cause. Conditions such as temporomandibular joint disorder (TMJ/TMD), orthodontic problems, narrow jaws, excessive tooth wear, clenching and grinding, cavities, dry mouth, and gum disease can all be associated with sleep-disordered breathing.

Dr. Robert J. Williams, DDS, and Dr. Robert C. Williams, DDS, FAGD, along with their clinical team, are trained to evaluate the upper airway—including the mouth, jaw, nasal passages, tongue, and throat—to help identify potential airway concerns. When appropriate, they work closely with medical and dental specialists to ensure patients receive comprehensive care for sleep-related breathing disorders.

For example, if Drs. Williams suspect nasal obstruction or observe enlarged or chronically infected tonsils, they may refer a patient to an Ear, Nose, and Throat (ENT) specialist for further evaluation. An ENT may recommend additional testing, such as a sleep study, or discuss medical and surgical treatment options to improve airway function.

Airway obstruction can also be influenced by oral and facial structures, such as a narrow palate, restricted jaw development, or bite-related issues. In these cases, Drs. Williams may provide restorative dental treatment or refer patients to an airway-focused orthodontist or oral and maxillofacial surgeon. These specialists utilize advanced techniques and procedures that can help expand the jaws, improve facial development, and create more space for healthy airway function and proper tongue posture.

In some cases, Drs. Williams may also recommend consultation with a myofunctional therapist, who specializes in strengthening and retraining the muscles of the face, lips, tongue, and airway. Myofunctional therapy can help promote proper nasal breathing, healthy tongue posture, and improved airway function during both the day and night.

Some oral signs that Drs. Williams and their team evaluate include:

• Tooth wear caused by bruxism (clenching and grinding) or airway-related acid reflux
• Effects of chronic mouth breathing, such as red, swollen gums and recurrent tooth decay
• Enlarged tonsils or narrowing of the airway at the back of the throat
• Jaw discomfort, clicking, or popping when opening and closing the mouth
• Tongue-tie and lip-tie restrictions
• Signs of restricted tongue space or improper tongue posture
• Bite irregularities that may contribute to airway dysfunction

By identifying these signs early, Drs. Williams and their team can help patients better understand the connection between airway health, sleep quality, oral health, and overall wellness.

Dental Treatment Options For Sleep Apnea

A poor bite, missing teeth, misaligned or narrow jaws and other dental abnormalities can further cause breathing problems. Depending on the particular issue, your dentist, orthodontist, or oral surgeon can correct them. Treatments include:

• Night Guard: Worn during sleep, this device can help prevent tooth grinding, as well as temporarily opening the bite to give the tongue more space, which can improve milder sleep breathing issues at night.
• Mandibular Advancement Device (AKA snoreguard): This is a removeable night time devices that temporarily moves the jawbone forward, opening the airway, especially for patients with sleep apnea. It is worn during sleep with or without a CPAP machine. It is can be more comfortable than the CPAP for some people and can also improve sleep apnea, snoring, and bruxism. It may be covered by medical insurance when a patient has a sleep apnea diagnosis from a sleep study.
• Palatal Expander: Attached to the teeth, or in some cases the palate itself, this device can widen a child’s upper jaws to correct occlusion issues such as crossbite, crowding and impacted teeth. It is important to begin this treatment as early as possible in childhood, while palates are still malleable, because adults’ palates essentially fuse and don’t respond as readily to these appliances, without surgical intervention. Palatal expanders can be an important component of treatment to reduce sleep apnea and restore proper functional nasal breathing. This is because the roof of the mouth is the floor of the nose, so by expanding the palate you effectively widen the nasal passageway. Pediatric dentists and orthodontists are being called to screen for airway issues and refer for expansion earlier and earlier, starting as early as age 3 or 4, since much of jaw and facial growth happens by age 6. Orthodontic correction and expansion with traditional orthodontics can still be helpful in adults to correct bites and leave more room for the tongue. There are also newer, more sophisticated techniques such as Surgically Facilitated Orthodontic Therapy (SFOT), mini-implant supported (TAD) expanders, Surgically Assisted Rapid Palatal Expansion (SARPE) and the DOME technique developed by Dr. Audrey Yoon, which can all allow for adults to form new bone in the palate or on the front of the jaw, and thus expand to improve the airway.
• Tongue and Lip Tie Release: Dr. Robert Williams, DDS and his hygienists have taken specialized training from Dr. Soroush Zaghi, MD, who has become the leading expert and researcher on tongue and lip tie in adults and children. He has developed an assessment to identify functional issues with tongue range of motion caused by a tongue tie and performs Functional Frenuloplasties to restore proper nasal breathing and tongue posture and thus treat sleep breathing disorders, along with myofunctional therapy.
• Jaw Surgery: In severe cases of sleep apnea, jaw surgery known as Maxillomandibular Advancement (MMA) may be an option. Performed by an Oral Maxillofacial Surgeon (OMS/OMFS), this form of facial skeletal surgery is done by making incisions inside the mouth in the bone in order to bring both jaws forward to leave more space for the tongue and open up the airway. It is often done in conjunction with orthodontics.

Myofunctional Therapy

Our office is one of the few in the area with hygienists on our team who are trained in myofunctional therapy. Our hygienist Krista has taken advanced training in this area and has been doing myofunctional therapy for over a year. Jenn is also starting her training this year!

Another possible cause of airway obstruction is muscle weakness of the tongue, mouth and upper throat. Myofunctional therapy consists of a system of techniques and exercises to strengthen the muscles of the lips, tongue, airway, and chewing and swallowing, enabling them to support effective nasal breathing during the day and night, which can reduce symptoms of bruxism, snoring, and sleep apnea.

Particularly in small children, it can be very effective in helping to guide jaw and facial growth. For example, by ensuring that the tongue is suctioned up to the palate at rest, myofunctional therapy can help expand jaws naturally in a developing child, and can be used along or in conjunction with orthodontics, tongue and lip tie release, and jaw surgery at any age.

Some myofunctional therapists are also breathing coaches, so they can help patients learn how to breath correctly through the nose day and night. Krista studied the Buteyko Breathing Method under Patrick Mckeown of the Buteyko Clinicic International, and is one of 16 accredited Buteyko Practicioners in California.

Myofunctional therapists are also trained to screen for anatomical issues related to the airway, such as tongue and lip tie, orthodontic issues, large tonsils, so that they can make the proper referrals to medical and dental specialists.

Myofunctional Therapy also can be useful to deter children from pushing their tongue against, and moving, their teeth, to help avoid orthodontics or orthodontic “relapse,” and helping parents eliminate bad habits like pacifier use, thumb sucking, or nail, tongue or cheek biting.

If you think you have sleep breathing issues, discuss them with Dr. Robert Williams, DDS at your next visit and visit Krista’s website Second Breath OMT for more information. It’s important to your quality of life to correct breathing problems as early as possible, and we will work with you to make sure you receive effective treatment.

Additional Reading

1. Why We Sleep by Mathew Walker, PhD
2. Sleep Interrupted by Dr. Steven Park
3. The Oxygen Advantage by Patrick McKeown
4. Gasp! Airway Health-The Hidden Path to Wellness by Dr. Michael Gelb and Dr. Howard Hindin
5. Jaws: The Story of a Hidden Epidemic by Sandra Kahn and Paul R. Ehrlich.
6. Tongue Tied by Richard Baxter, DMD, MS
7. Why Zebras Don’t Get Ulcers by Robert Sapolsky, PhD