Sometimes it’s a Big Deal
By Edward Bruno D.D.S., M.S.D.
I am an orthodontist in Chico with 27 years in private practice. It has been my privilege to work with most of the dentists, and many physicians, in the north state over that time. I have also served 7 years on the Butte County Cleft Palate Panel, giving me an opportunity to work with a variety of health professionals.
Medicine and dentistry progresses through both scientific evidence, and by learning from the successes and mistakes of the past. The use, and arguably overuse, of tonsillectomy and adenoidectomy in the mid-twentieth century is well documented; reaching its peak in the 1950s. Concerns were often for recurrent throat and ear infections. Today, Otolaryngologists (ENTs), that I have the opportunity to consult, are thoughtful about recommending these surgeries. The medical evidence regarding treatment outcomes and advent of improved medications to address infection, congestion, and allergy are among the changes allowing a cautious approach.
My particular area of interest concerns not so much infectious disease, but rather the effect of chronic nasal obstruction on the development of the face, jaws and dentition. Children who are unable to breathe through the nose due to partial or total obstruction may develop several growth disturbances. These characteristics were long ago termed “Adenoid Facies” (Photo #1) and include: long, narrow facial form, narrow nose, upwardly bowed upper lip, mouth-open posture, sleepy expression, high-narrow palate with dental crowding, and reduced forward growth of the lower jaw causing the upper front teeth to protrude. There is some disagreement about whether nasal obstruction is a cause or an effect of those features, but one thing is clear: correction of the blockage and re-establishment of nasal breathing improves the direction of development of jaws and face.
It is rare to see all of these features in one child, but presence of more than one raises the likelihood that mouth breathing is affecting development. Many of these changes can be explained by commonsense appreciation of the mechanisms of growth of the face and dentition.
Bones and teeth grow and develop through a combination of genetics and the influence of the soft tissues in which they grow. The relationship is clear (although oversimplified) if we use the shape of the upper dental arch and palate as an example. The upper dental arch is squeezed between the tongue pushing outward and cheeks balancing that force by pushing inward. The result is usually the “U” shape of a normal dental arch. If the mouth is open and the tongue carried low to allow mouth breathing, the cheeks push in and are not balanced by the tongue in the upper part of the mouth. This “squishes” the upper dental arch and encourages development of a narrow “V” shape rather than the normal “U” shape. (Photo #2) The longer in life this process continues, the more difficult the challenge for the orthodontist.
In what other mischief is mouth breathing implicated? In children and adolescents it is related to learning difficulties, behavioral symptoms similar to ADD/ADHD, sleep apnea, and reduced physical stamina. Breathing only through the mouth, rather than both mouth and nose during athletics, reduces oxygen uptake by the lungs.
So, how can the orthodontist and/or the physician address this problem? Similar to adeno/tonsillectomy, early orthodontic treatment (during a period with some permanent teeth and some baby teeth) has had periods of relative favor and disfavor in the orthodontic community. The reasons for a trend away from early treatment included both research evidence on treatment outcomes, and the advent of improved treatment modes. Most orthodontists have found that modern techniques and innovations allow us to treat severe dental crowding and moderate jaw disproportions after waiting for all of the permanent teeth to emerge. This is efficient and convenient for busy teens, parents and the orthodontist. But, jaw, dental, and facial development is often nearly complete by that time. The behavioral and physical development problems mentioned above may have a truly negative effect if a youngster has been mouth breathing much of that time. This is resulting in a swing back toward acceptance of the value of early treatment.
A 2002, systematic review in the prestigious ENT journal, Laryngoscope, concluded that “abnormal dentofacial growth” is an indication to consider adenoidectomy. ENT physicians will often seek to correct nasal obstruction medically first; and that is as it should be. But, in those instances when medical management is less than fully effective, or in instances of too-frequent recurrence, the ENT specialist may recommend surgery and I encourage parents to heed that recommendation. Research at the Karolinska Institute in Sweden, in the 1970s, demonstrated remarkable changes in facial growth in mouth breathing children treated with adenoidectomy to re-establish nasal breathing. (Photo #3)
A constricted upper jaw and palate can be corrected readily with orthodontic care in growing children. (Photo #4) It is important to understand that the roof of the mouth (palate) is also the floor of the nose. The American Association of Orthodontists recommends an orthodontic screening for children by age 7.
There are instances when conservative medical management can address the entire problem. At other times, surgical treatment by ENT physicians, early orthodontic care, or both, might be required, depending on the specifics of the problem.
Bottom line: There is no single silver bullet solution. Each mouth breathing child deserves a careful evaluation and care tailored to their special needs. At times, it requires teamwork between dentists, orthodontists, and physicians.
Inquiries for literature citations may be sent to:
Dr. Edward Bruno
1068 East Avenue, Suite C
Chico, CA 95926