“The time to fix the roof is when the sun is shining” President John F. Kennedy
Oral-Facial Clues of an Impaired Mouth
One look at the patient from the side while standing or seated, and I can tell if she/he is likely to have airway-related sleep problem. So can you.
The mouth drives health not only through eating and drinking, but also through sleep and airway. Signs of airway struggle often show up in the mouth long before health slides downhill too far. “CSI” in my office stands for chair side investigation. Here is a partial list of the more common features of an impaired mouth.
Postural Clues to Pinched Airway
When the airway is too narrow to deliver enough oxygen, the neck will extend forward, and the head may tilt backward, in an effort to get more air. Keep the same head-neck posture while lying down achieves the recommended position for CPR (cardiopulmonary resuscitation).
This postural compensation leads over time to a telltale hump back. Persistent pain or stiffness in the back of the neck and shoulders are frequent symptoms associated with impaired mouth.
Liao’s Sign refers to an upper lip in profile view that is flat or curled, which suggests a deficient maxilla and implicates a pinched airway in back of the mouth.
Oral Anatomy and Definitions
A few anatomical terminology here may be helpful before we go over the oral-facial (orofacial) signs of an impaired mouth and airway:
- Uvula: that flexible and pointy projection at the end of the soft palate in the back end of the roof of the mouth.
- Friedman tongue position is a useful clinical indicator for predicting obstructive sleep apnea (OSA). (1) The less the uvula and tonsils are visible, the higher the severity of OSA.
- Malocclusion: dental term for bad bite, which can include crowded, spacey, buck, or crooked teeth, deep overbite, underbite (weak chin), clicking/popping/locking jaw joints, and others.
- Cross bite: an abnormality when the lower teeth are on the outside of upper teeth. Think of the upper arch as a shoe, and the lower as a foot. Normally, the upper jaw should be wider than the lower. Cross bite suggests deficient upper jaw, either in size, or in position.
- Overbite: the vertical overlap between the upper and lower front teeth. A deep overbite means most of the lower front teeth are covered by upper front teeth with the back teeth touching. An ideal overbite and overjet is only 1-2 mm. A deep overbite (over 3 mm) implies reduced oral volume for the tongue and therefore a pinched airway.
- Overjet: the horizontal distance between the upper and lower front teeth. The ideal overjet is also only 1 to 2 mm. The larger the overjet (“underbite”), the closer the lower jaw is to the throat, and the more the tongue is in the airway. A weak chin is the surface expression of an excessive overjet. A weak chin means pinched airway.
Dental Clues of Impaired Mouth
A shortlist of orofacial signs of impaired mouth and pinched airway in and around the mouth includes:
- Teeth Grinding, as indicated by matching wear facets on teeth can be clinical clues of teeth grinding (sleep bruxing in medical research). “… patients with anxiety and sleep-disordered breathing have a higher number of risk factors for sleep bruxism, and this must raise concerns about the future of these individuals.” (2)
- Tooth prints on the sides of the tongue (crenation). “We feel the finding of tongue scalloping is a useful clinical indicator of sleep pathology and that its presence should prompt the physician to inquire about snoring history.” (3)
- Abfractions: Ab- means missing, and abfraction means missing a piece of tooth structure at the gum line. Abfractions often are very sensitive to cold and brushing. Abfractions come from teeth grinding was first proposed in 1984. (4) This was subsequently confirmed in 2002. (5)
- The whites of the eyes (sclera) showing between the lower eyelids and irises, the colored parts of the eyes: This suggests an underdeveloped maxilla. (6)
- Narrow nostrils and a small mouth with dry or chapped lips: These are indications of mouth breathing — see the photos above.
- Tori in the upper or lower jaw: Torus (pl: tori): a bony outgrowth on the roof of the mouth, cheek side of the upper or lower jaws, or the tongue side of the lower jaw. Tori indicate 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.” (7)
- A weak chin from a retruded jaw and/or a large overjet: “Overjet was associated with the severity of obstructive sleep apnea syndrome in non-obese patients,” concluded a study from Japan’s Nagoya University Orthodontic Clinic. (8) In the case below, oral appliance therapy redeveloped the “three-foot den” so there is space in the mouth for the tongue to leave the airway.
- Facial grooves and wrinkles around the mouth: This is not simply a cosmetic issue, in my experience. These deep grooves and wrinkles come from a lifetime of improper swallowing a minimum of 1,000 times a day.
Holistic Mouth Bites
- An impaired mouth offers many oral-facial clues for “the crime scene investigation” leading to impaired mouth as the culprit.
- The more the patient is aware of impaired mouth’s signs and symptoms, the earlier the diagnosis can be professionally confirmed and treated.
- Dentists trained in malocclusion, temporomandibular joint disorder (TMJD), and sleep medicine can recognize the oral, facial, and dental signs of OSA while the patient is young — long before OSA manifests.
- Xavier Barceló and others, “Oropharyngeal Examination to Predict Sleep Apnea Severity,” Archives of Otolaryngology — Head & Neck Surgery 137, no. 10 (2011): 990–996, DOI: 1001/archoto.2011.176, PMID: 22006776.
- Maurice M. Ohayon, Kasey K. Li, and Christian Guilleminault, “Risk Factors for Sleep Bruxism in the General Population,” Chest 119, no. 1 (2001): 53–61, DOI: 1378/chest.119.1.53, PMID: 11157584.
- Todd M. Weiss, Strahil Atanasov, and Karen H. Calhoun, “The Association of Tongue Scalloping with Obstructive Sleep Apnea and Related Sleep Pathology,” Otolaryngology — Head & Neck Surgery 133, no. 6 (2005): 966–971, DOI: 1016/j.otohns.2005.07.018, PMID: 16360522.
- William C. Lee and W. Stephan Eakle, “Possible Role of Tensile Stress in the Etiology of Cervical Erosive Lesions of Teeth,” Journal of Prosthetic Dentistry 52, no. 3 (1984): 374–380, DOI: 1016/0022-3913(84)90448-7, PMID: 6592336.
- S. Rees, “The Effect of Variation in Occlusal Loading on the Development of Abfraction Lesions: A Finite Element Study,” Journal of Oral Rehabilitation 29, no. 2 (2002): 188–193, DOI: 10.1046/j.1365-2842.2002.00836.x, http://www.fo.ufu.br/sites/fo.ufu.br/files/Anexos/Comunicados/Rees_JS_2002.pdf.
- Dave Singh and James A. Krumholtz, Epigenetic Orthodontics in Adults (Chatsworth, CA: Smile Foundation, 2009), 27.
- Dave Singh, “Guest Editorial on the Etiology and Significance of Palatal and Mandibular Tori,” CRANIO: The Journal of Craniomandibular & Sleep Practice 28, no. 4 (2010): 213–215, PMID: 21032973, http://www.smileprofessionals.com/uploads/Cranio-2010-Tori-Singh.pdf.
- Etsuko Myiao and others, “The Role of Malocclusion in Non-obese Patients with Obstructive Sleep Apnea Syndrome,” Internal Medicine 47, no. 18 (2008): 1573–1578, DOI: 2169/internalmedicine.47.0717, PMID: 18797115.