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In October 2017, the American Dental Association (ADA) re-leased a policy statement addressing dentistry’s role in sleep-re-lated breathing disorders.1 The policy encourages dental pro-
fessionals to screen their patients for Obstructive Sleep Apnea (OSA), Upper Airway Resistance Syndrome (UARS), and other breathing disorders. The ADA advocates working in collabora-tion with other trained medical colleagues and emphasizes the effectiveness of intra-oral appliance therapy for treating patients with mild to moderate OSA and CPAP-intolerant patients with severe OSA.
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CONTINUING education
A Checklist for Evaluation of Potential Airway & Breathing Disordersby DeWitt C. Wilkerson, DMD
Educational aimsThis article is written in behalf of
all clinical team members, to orient each of us in the basic understand-ing of the signs and symptoms of dys-functional breathing and sleep com-monly found in our dental practice population. The dedicated clinician is encouraged to read each of the ref-erences from this practical article.
Expected outcomesDental Sleep Practice subscrib-
ers can answer the CE questions on page 26 to earn 2 hours of CE from reading this article. Correctly answer-ing the questions will demonstrate the reader will:• Gain a basic understanding of the
signs and symptoms of dysfunc-tional breathing and sleep.
• Have a practical clinical guide which can be implemented im-mediately.
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With the endorsement of the ADA, screening and treating sleep-related breath-ing disorders has become the newest focus of integrative dental medicine. The pur-pose of this article is to provide a simpli-fied Checklist to guide the dental team in reviewing each patient’s:
• History (signs & symptoms) • Clinical Evaluation • Screening & Testing
History (signs & symptoms) 1. MOUTHBREATHER - + Are you aware being a mouth breather?
Mouth breathing is considered dysfunc-tional breathing, because it bypasses the critical physiologic benefits of nasal breath-ing.2 Through the nose, air is humidified, warmed, sterilized/anti-microbial effect of nitric oxide produced in the para-nasal si-nuses, and the breathing rate is controlled to help maintain an optimum carbon diox-ide-oxygen ratio in the bloodstream (Bohr Effect). Mouth breathing eliminates the pos-sibility of ideal physiologic breathing, al-lowing “dirty air” containing microbes, pol-lutants, pesticides, smog, allergens, pollen, and spores, to name a few, to pass through the mouth straight to the lymphoid tissues of the adenoids and tonsils. This can result in both inflammation and infection in the posterior throat.
2. SNORE - + Are you aware of snoring in your sleep?
Snoring is a sign of airway blockage as the tissues of the soft palate vibrate against the posterior wall of the pharynx. This can be ac-companied by the tongue dropping back as
well. Approximately one in three snorers also suffers from obstructive sleep apnea.
3. SLEEP APNEA - + Have you been diagnosed with Sleep Ap-nea or been observed to stop breathing in your sleep?
Obstructive Sleep Apnea is a very seri-ous breathing disorder that has significant systemic effects due to mechanical col-lapse of the posterior throat airway. An apneic event occurs when breathing ceases for 10 seconds or longer accom-panied by drops in oxygen saturation in the bloodstream. During sleep, multiple events in intervals of several minutes or longer can mimic the experience of choking and stimulate activation of the Sympathetic Nervous System, “Fight or Flight” response. Stress hormones, in-cluding Cortisol, are released into the bloodstream, producing an acute ex-citation of the heart rate. The increase in blood flow is an attempt to deliver needed oxygen throughout the body. Chronic elevated cortisol levels in the blood can produce several deleterious effects including increased blood pres-sure, cardiac arrhythmia, insulin resistance, and leptin/ghrelin imbalance. An increased hunger drive can be stimulated by imbalanc-es between leptin and ghrelin.
Central Sleep Apnea (CSA) is a CNS dis-order in which the respiratory center in the brain fails to transmit a signal to the body to inhale. CSA frequently occurs among peo-ple who are seriously ill from other causes: chronic heart failure, diseases of and injuries to the breathing control centers in the brain-
Dr. DeWitt “Witt” Wilkerson graduated from the University of Florida, College of Dentistry in 1982, the same year he joined the Dawson group private practice in St. Petersburg, Florida, and where he presently practices. He is Past President of the American Equilibration Society, Immediate Past-President of the American Academy for Oral-Systemic Health, Senior Faculty/Lecturer and Director of Dental Medicine at the Dawson Academy, an Adjunct Professor of Graduate Studies at the University of Florida, College of Dentistry, and Past Associate Faculty and Special Lecturer at the L.D. Pankey Institute.
Dr. Wilkerson lectures both nationally and internationally on the subjects of Restorative Dentistry, Dental Occlusion, TM Disorders, Airway/Dental Sleep Medicine, and Integrative Dental Medicine. He has taught over
600 days of lectures and hands-on instruction at the Dawson Academy.Personally, Witt and his wonderful wife, Pat, have been married 37 years and are the proud parents of Todd, Whitney, Ryan, and
a beautiful 3 year old granddaughter, Carolina. The Wilkerson family has been privileged to participate in many dental missions trips including Romania, Kenya, and Nicaragua.
CONTINUING education
History1. Mouthbreather2. Snore3. Sleep Apnea4. Poor Sleep Quality5. Daytime Sleepiness6. Nasal Congestion7. Forward Head
Posture8. Tongue-tie9. Chronic Cough10. Deviated Septum
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stem, Parkinson’s disease, stroke, kidney fail-ure, and even severe arthritis with degener-ative changes to the cervical spine and base of the skull. It is seen among users of opiates. Idiopathic CSA is a description used when the cause is unknown.
Mixed Apnea describes the simultaneous occurrence of both OSA and CSA.
4. POOR SLEEP QUALITY - + Do you sleep poorly or wake up during the night?
Breathing disorders during sleep disrupt the normal sleep pattern. Stimulation of the Sympathetic “Fight or Flight” response to de-creased oxygen levels, the release of steroid hormone Cortisol from the Adrenal glands, and increases in heart rate are all involved in producing arousals from deeper to lighter sleep levels or even waking up. Frequent uri-nation at night is a common side effect.
5. DAYTIME SLEEPINESS - + Do you feel tired and sleepy during the day?
Failure to spend adequate time in deeper sleep stages produces non-restorative sleep and its consequences: daytime fatigue and sleepiness.
6. NASAL CONGESTION - + Do you experience frequent nasal con-gestion or difficulty breathing through your nose?
Nasal congestion due to allergies from food or environment, nasal stenosis, deviated septum, nasal polyps, turbinate enlargement, and/or acute and chronic sinusitis, will affect breathing and often cause a conversion to dysfunctional mouth breathing. Eustachian tube blockage can produce a fullness feeling in the ears.
7. FORWARD HEAD POSTURE - +Does your neck bother you and do you find yourself in a forward head posture?
“Mouth-breathing Syndrome” is char-acterized by significant nasal obstruction, whereby an effort to overcome this resistance increases the work of accessory muscles of inspiration. Furthermore, forward head posture, common among mouth breathers, facilitates the air to enter the mouth which can lead to a deterioration of the pulmonary function. Chronically, the hyperactivity of the neck muscles may be associated with cervical changes that, as a result, can influ-ence temporomandibular disorders (TMD) and spine cervical disorders.3
8. TONGUE-TIE - + Do you have a tongue-tie or any tongue restrictions affecting sucking, swallowing or speech?
A short lingual frenulum has been associ-ated with difficulties in sucking, swallowing and speech. The oral dysfunction induced by a short lingual frenulum can lead to oral- facial dysmorphosis, decreasing the size of upper airway support. Progressive change in-creases the risk of upper airway collapsibility during sleep.4
9. CHRONIC COUGH - + Do you have a chronic cough, sore throat, or difficulty swallowing?
Chronic cough and similar throat issues are highly correlated with Sleep Apnea and Gastroesophageal Reflux Disease (GERD), which often occur together. It’s reported that 80% of the 60 million Americans who’ve been diagnosed with GERD report worse symptoms at night, and 3 in 4 wake up rou-tinely from sleep.
Chronic cough and similar throat issues are highly correlated
with Sleep Apnea and Gastroesophageal Reflux Disease (GERD), which
often occur together.
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10. DEVIATED SEPTUM - + Are you aware of having a deviated septum or nasal deformity or damage?
A deviated septum can be present from birth, be the result of poor maxillary develop-ment, or can occur after injury. It can contrib-ute to difficulty breathing through the nose, nasal congestion, recurrent sinus infections, nosebleeds, difficulty sleeping, snoring, sleep apnea, headaches and post-nasal drip.
Clinical Evaluation1. NECK CIRCUMFERENCE > 16” Women, > 17” Men
It has been demonstrated, through sever-al studies, that enlarged necks are associat-ed with increased soft tissue volume in the throat area.5 Neck size can be associated with being overweight, same as waist size.
2. MALLAMPATI > 2The Mallampati Score6 comprises a visual
assessment of the distance from the tongue base to the roof of the mouth, and therefore the amount of space for an adequate airway. The score is assessed by asking the patient, in a sitting posture, to open the mouth and pro-trude the tongue as much as possible, rating in 4 classes.
• Class 1: Soft palate, uvula, fauces, pillars visible.
• Class 2: Soft palate, uvula, fauces visible.
• Class 3: Soft palate, base of uvula visible.
• Class 4: Only hard palate visible.A higher Mallampati score is a predictor
for risk of OSA and can be a helpful screening tool during the clinical examination. How-ever, its role in predicting severity of OSA remains doubtful and needs further study.7 It should be noted that some individuals with a Mallampati 1 or 2 may have serious airway compromise.
3. SCALLOPED TONGUEThe presence of tongue scalloping has
shown a high correlation for abnormal AHI, and nocturnal desaturation. The presence and severity of tongue scalloping has shown a positive correlation with increasing Malla-mpati. In high-risk patients, tongue scallop-ing has been found to be predictive of sleep pathology. Tongue scalloping is a useful clin-ical indicator.8
4. 40% TONGUE RESTRICTION (Tongue-tie)
A normal range of free tongue movement is greater than 16 mm.9 Ankyloglossia can be classified into 4 classes based on Kotlow’s as-sessment(10) as follows;
• Class I: Mild ankyloglossia: 12 to 16 mm,
• Class II: Moderate ankylo-glossia: 8 to 11 mm,
• Class III: Severe ankyloglos-sia: 3 to 7 mm,
• Class IV: Complete ankylo-glossia: Less than 3 mm.
Class III and IV tongue-tie cate-gory should be given special con-sideration because they severely restrict the tongue’s movement. Restrictions include limitations of movement protrusively, laterally and vertically.
One screening evaluation involves: 1. Have the patient open their mouth as
wide as possible. Normal maximum opening is 40-50 mm.
2. While maximally open, raise the tip of the tongue, attempting to touch the incisive papilla behind the upper central incisors. Successful touching represents “normal” tongue mobility. Tongue restrictions can be visualized as a percentage of movement from rest to full extension towards the in-cisive papillae. 40% restriction or greater often has significant clinical implications.
5. NASAL STENOSISA simple observation can be made by
having the patient breathe in and out through the nose. Does the nostril on one or both sides collapse during nasal breathing? This provides a visible indicator of nasal airway collapse or obstruction. It would be common that these patients struggle with upper airway resistance and default to mouth breathing.
6. SKELETAL PROFILEMaxillary and/or mandibular skeletal
underdevelopment can compromise airway volume.11 Arnett’s True Vertical12 is a useful assessment for mandibular retrusion, maxil-lary retrusion, and bimaxillary (maxillo-man-dibular) retrusion, by observing the patient’s profile, facing to the right.
CONTINUING education
Clinical Evaluation1. Neck Circumference
> 16" Women, > 17" Men2. Mallampati >23. Scalloped Tongue4. 40% Tongue Restriction/
Tongue-tie5. Nasal Stenosis6. Skeletal Profile
A line dropped vertically down from the nose-lip intersection (SN) relates ideally to the fully developed lower face when:
Upper Lip = 2-5 mm in front of the lineLower Lip = 0-3 mm in front of the line Chin Point = -4-0 mm behind the line. Measurements less than these ranges can
implicate craniofacial, mid-face underdevel-opment, with increased risk for airway com-promise.
Screening & TestingSCREENING: HIGH RESOLUTION PULSE OXIMETRY (HRPO)
Overnight HRPO monitors two signifi-cant factors that relate to healthy or dysfunc-tional breathing.
1. SO2 – Oxygen saturation is the fraction of oxygen-saturated hemoglobin rela-tive to total hemoglobin (unsaturated + saturated) in the blood. The human body requires and regulates a very pre-cise and specific balance of oxygen in the blood. Normal blood oxygen lev-els in humans are considered 95–100 percent. If the level is below 90 per-cent, it is considered low (hypoxemia). Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart. Continued low oxygen levels may lead to respiratory or cardiac arrest.13
2. Pulse Rate – During non-REM sleep, the pulse rate tends to slow down 14-24 beats per minute, compared with wakefulness. The average heart rate range during all 3 stages of non-REM sleep is between 60-100. Some indi-viduals may have a normally slower or faster heart rate range. Non-REM rep-resents roughly 75-80% of time asleep. REM sleep includes periods of dream-ing and increased heart rate, with more variability. REM is often concen-trated in the last few hours of sleep. HRPO can screen for disordered breathing during sleep by observing the recorded “Delta” of both SO2 and Pulse Rate. Delta involves the differ-ence between high and low values. Large swings in both SO2 and Pulse Rate over short intervals, on multiple occasions throughout sleep, may indi-cate a breathing disorder. Precise in-terpretation is often difficult.14
TESTING: HOME SLEEP TESTING (HST)Home sleep testing has become a stan-
dard for evaluation and diagnosis of sleep disorders in recent years. Though less infor-mation is gathered relative to polysomnog-raphy (PSG) studies, the accuracy appears comparable15. Most home testing recorders can track time of the test period, but not sleep time, which requires EEG signals. They also gather data about oximetry, pulse rate, sleep position, apnea & hypopnea episodes, snoring, and chest effort. The reports include an AHI. A new term, REI, or Respiratory Event Index, has been adopted by the Ameri-can Academy of Sleep Medicine to designate results from testing when true sleep time is not measured. There is a lot of other data on even a ‘simple’ test that provides insight to the patient’s sleep.
Note: Dentists are not qualified or li-censed to interpret sleep apnea. HST should be interpreted by a Board Certified Sleep Physician. Many HST manufacturers provide an interpretation service. Dentists are the ideal health professionals to screen patients and gather studies for potential airway dis-orders. When HST reveals significant signs of breathing dysfunction and elevated AHI, referral for an overnight laboratory PSG will analyze important additional information such as EEG and CSA. The results may sig-nificantly altar the treatment plan.
Dr. Tom Colquitt, Past President of the American Academy of Restorative Dentistry (AARD), addressed the 2016 session of that Academy with the following critical state-ment: “Other than emergency care, the first procedure performed by every dentist, for ev-ery patient, of any age should be a proper air-way examination and evaluation of breathing function.”
Airway and breathing disorders are be-coming an increasing area of emphasis in Dentistry.
Form follows function.Properly functioning nasal breathing,
tongue posture, and swallowing patterns greatly influence a properly formed dental occlusion. On the contrary, dysfunctional mouth breathing, tongue posture, and swal-lowing patterns greatly influence an improp-erly formed dental malocclusion. This may include TMD symptoms, clenching, brux-ism, tooth abrasion and erosion, headaches, GERD and broad systemic effects.
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Screening & Testing• Screening: High
Resolution Pulse Oximetry (HRPO)
• Testing: Home Sleep Testing (HST)
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Brent Bauer M.D., Internist and Editorial Board member for the Mayo Clinic Health Letter wrote an article entitled, Buzzed on Inflammation.16 “Inflammation is the new medical buzzword. It seems as though every-one is talking about it, especially the fact that inflammation appears to play a role in many chronic diseases.” One of the most important sources of systemic inflammation is related to breathing dysfunction. For example, OSA may activate the sympathetic/adrenomedul-lary and the hypothalamic-pituitary-adrenal (HPA) axis limbs of the neurologic stress sys-tem.17 Nocturnal micro-arousals and awak-enings are associated with chronic cortisol release. Over days, months and years this can influence a number of inflammatory related problems including insulin resistance and diabetes; dysregulation of the hunger hor-mones, leptin and ghrelin, leading to weight gain and obesity, and OSA directly affects the vascular endothelium by promoting inflam-mation and oxidative stress while decreasing NO availability and repair capacity.18
The demands of clinical practice are ever-increasing. Dentists must be aware of more health concerns every day. Patients are asking about airway because they read about health effects of sleep related breathing dis-orders and look to their trusted dentist for
direction. You can be ready to help them by using the provided Checklist to identify air-way and breathing related disorders in your dental practice.
Properly functioning nasal breathing, tongue posture, and swallowing patterns greatly influence a properly formed dental occlusion. On the contrary, dysfunctional mouth breathing, tongue posture, and swallowing patterns greatly influence an improperly formed dental malocclusion.
1. ADA Adopts Policy on Dentistry’s Role in Treating Obstructive Sleep Apnea, Similar Disorders. ada.org October 23, 2017 News Releases
2. The Oxygen Advantage. Patrick McKeown 2015, William Morrow/Harper Collins Publisher
3. Implications of mouth breathing on the pulmonary function and respiratory muscles. Vern, H Antunes, A Milanesi J et.al Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016
4. A frequent phenotype for pediatric sleep apnea: short lingual frenulum. Guilleminault C, Huseni S, Lo L ERJ Open Research 2016 2: 00043-2016
5. Which Oropharyngeal Factors Are Significant Risk Factors for Obstructive Sleep Apnea? An Age-Matched Study and Dentist Perspectives Nat Sci Sleep. 2016; 8: 215–219
6. Mallampati Score, Wikipedia
7. Importance of Mallampati score as an independent predictor of obstructive sleep apnea. Kanwar M, Jha R European Respiratory Journal 2012 40: P3183;
8. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Weiss TM, Atanasov S, Calhoun KH Otolaryngol Head Neck Surg. 2005 Dec;133(6):966-71.
9. Ankyloglossia and its management. Chaubal T, Dixit M J Indian Soc Periodontol. 2011 Jul-Sep; 15(3): 270–272.
10. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Kotlow LA. Quintessence Intl. 1999;30:259–62.
11. Impact of Mandibular Distraction Osteogenesis on the Oropharyngeal Airway in Adult Patients with Obstructive Sleep Apnea Secondary to Retroglossal Airway Obstruction. Ramanathan Manikandhan, Ganugapanta Lakshminarayana, Pendem Sneha, Parameshwaran Ananthnarayanan, Jayakumar Naveen, and Hermann F. Sailer. J Maxillofac Oral Surg. 2014 Jun; 13(2): 92–98.
12. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. William Arnett, DDS, FACD, Jeffrey S. Jelic, DMD, MD, Jone Kim, DDS, MS, David R. Cummings, DDS, Anne Beress, DMD, MS, C. MacDonald Worley, Jr, DMD, MD, BS, Bill Chung, DDS, Robert Bergman, DDS, MSh. American Journal of Orthodontics and Dentofacial Orthopedics Volume 116, Number 3 September 1999
13. Oxygen saturation(medicine) Wikipedia
14. Examination of pulse oximetry tracings to detect obstructive sleep apnea in patients with advanced chronic obstructive pulmonary disease. Adrienne S Scott, Marcel A Baltzan, and Norman Wolkove Can Respir J. 2014 May-Jun; 21(3): 171–175
15. Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep-disordered breathing: a systematic review and meta-analysis Mohamed El Shayeb, MD MSc, Leigh-Ann Topfer, MLS, Tania Stafinski, PhD, Lawrence Pawluk, MD, Devidas Menon, PhD. CMAJ. 2014 Jan 7; 186(1)
16. “Buzzed on inflammation.” Brent Bauer MD, Mayo Clinic Health Letter. N.p., n.d. Web. 16 Sept. 2014. http://health letter.mayoclinic.com/editorial/editorial.cfm/i/163/t/Buzzedon inflammation
17. Buckley TM, Schatzberg AF. On the interactions of the hypothalamic-pituitary-adrenal (HPA) axis and sleep: normal HPA axis activity and circadian rhythm, exemplary sleep disorders. J Clin Endocrinol Metab. 2005;90:3106–3114.
18. Inflammation, Oxidative Stress, and Repair Capacity of the Vascular Endothelium in Obstructive Sleep Apnea. Sanja Jelic, MD, Margherita Padeletti, MD, Steven M. Kawut, MD, MS, Christopher Higgins, MD, Stephen M. Canfield, MD, Duygu Onat, PhD, Paolo C. Colombo, MD, Robert C. Basner, MD, Phillip Factor, DO, and Thierry H. LeJemtel, MD. Circulation. 2008 Apr 29; 117(17): 2270–2278.
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1. Mouthbreathing is considered dysfunctional breathing because ____________.a. It interferes with swallowingb. It could lead to inflammation in the throatc. Passing air over the tonsils produces excess
nitric oxided. Lip dryness results in increased chance of
infection
2. Using a checklist in your office for assessing airway ____________.a. Enables your office to implement the ADA
Policy Statement on Sleep Related Breath-ing Disorders
b. Provides you an opportunity to evaluate one of the key parameters of health
c. Distinguishes your office from those who only provide typical dental services
d. All of the above
3. During sleep apnea events ____________.a. Cortisol is released into the bloodstreamb. Breathing can stop for 5 seconds or longerc. Leptin increases the heart rated. The body is more likely to develop central
sleep apnea
4. Central Sleep Apnea ____________.a. Is triggered by many of the same problems
that create obstructive sleep apnea
b. Is less common at higher altitudes due to relatively larger percentage of CO2 in the air
c. Primarily is a central nervous system disorderd. Is more readily observed by bed partners
due to lack of breathing effort
5. Sleep Quality may be assessed by questioning ____________.a. Whether the patient moves frequently
during sleepb. If dreams can be recalled c. How many hours the patient is able to stay
asleepd. How often they have to use the bathroom
during the night
6. Nasal Breathing ____________.a. Nasal patency is best left to the otolaryngol-
ogists to addressb. Is part of any airway assessment by a trained
providerc. Contributes to sleep apnea because it re-
quires more work than mouth breathingd. Can be improved by using EPAP devices
7. Dentists should evaluate their patient’s neck posture ____________.a. So they can properly adjust the dental chair
for comfortable proceduresb. Because it influences how far forward the
jaw can go with an oral appliance
c. It is a major clue for airway behavior during sleep
d. Because chronic hyperactivity of neck mus-cles can influence TMD
8. Scalloped Tongue ____________.a. Is pathognomonic for bruxismb. Means there is insufficient room for the
tongue within the dental archesc. Is positively correlated with a crowded oro-
pharynxd. Could be any or all of these
9. Arnett’s True Vertical ____________.a. Requires a cephalometric tracing to evaluateb. Is a measurement of the quality of prior or-
thodontic therapyc. Is a useful tool to assess how skeletal devel-
opment relates to airway volumed. Is used to avoid path of insertion problems
when incisors are flared facially
10. Respiratory Event Index ____________.a. Is used in sleep labs to correlate obstructive
and central apnea with brain responsesb. Is more accurate than Apnea Hypopnea In-
dex in assessing airway problemsc. Is made up of snoring sounds plus body
movements divided by test timed. Is a new term from American Academy of
Sleep Medicine for use with HST
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A Checklist for Evaluation of Potential Airway & Breathing Disorders by DeWitt C. Wilkerson, DMD
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