by Felix Liao
Impaired Mouth Clues Uncovered by B.N.’s CSI
Examining B.N.’s teeth and other oral structures, I saw advanced wear and tear on the edges of her upper and lower front teeth, suggestive of teeth grinding—a common finding in patients with a narrowed oral airway. In addition, her upper and lower front teeth were too narrow by 4 mm and 5 mm, respectively, and her uvula was not visible. That, too, is a marker for sleep-apnea risk.
Three-dimensional CT imaging showed she had neck vertebrae misalignment, accounting for her aches and pains, and an airway in the orange-red zone while standing, which means it was more likely to collapse during sleep.
The Holistic Mouth Solutions That B.N. Implemented
B.N. choose oral-appliance therapy over CPAP, so custom oral appliances designed to widen and realign both jaws were made and fitted over her upper and lower teeth. She was instructed to wear them fourteen to sixteen hours a day, including during sleep, and to:
Turn the gear for widening once a week.
Return for a progress check once a month.
Use blackout blinds in the bedroom and no TV, computer screens, tablet, or cell phone in the bedroom.
Eat a smaller portion of dinner before 7:00 p.m. or four hours before bedtime.
Have lights out by 10:30, and be asleep by 11:00 p.m. to flow with the circadian rhythm.
Results Produced by Holistic Mouth Solutions for B.N.
After fifteen months of just wearing oral appliances to sleep and without diet and lifestyle changes, B.N. reported that her blood pressure was down by 13/10, from 140/87 to 127/77. Depending on your doctor’s criteria, normal blood pressure is either 120/80 millimeter of mercury plus your age, or less than 120/80.(2)
“Now I need to adjust my medication with my doctor,” she said. Moreover, she said, “My blood pressure does not shoot up right away like it used to when I forget my medication. My blood pressure now stays normal for a couple of days even when I don’t take the meds.
“The aches and pains in my shoulders are improving, too. And I’m not as tired as I used to be—which is important when you’re taking care of six kids!”
How can oral-appliance therapy do this? By making the tongue less of an airway obstructor so that her body can sleep in peace, instead of confronting a tiger in her throat.
According to Japanese research, an individually prescribed oral appliance can lower high blood pressure in patients with mild to moderate OSA by 4.5/3.0 millimeter of mercury over an average of sixty days.(3) B.N.’s drop of 13/10 was much more dramatic, perhaps because she had both upper and lower expander appliances to create a more spacious habitat for her tongue—a point we will return to later.
B.N. has been instructed to repeat her sleep test to confirm her progress in accordance with the American Academy of Sleep Medicine guidelines.
Holistic Mouth Bites
Half of all OSA patients have high blood pressure.
Blood pressure can be lowered in medically diagnosed OSA patients when an impaired mouth is treated with oral appliances.
The results can be even more dramatic when both upper and lower appliances are used to create a more spacious habitat for the tongue.
By considering high blood pressure as a symptom of Impaired Mouth Syndrome, a holistic mouth checkup may help identify pinched airway as a root cause or contributor of sleep apnea and drug-resistant hypertension.
Chapter Nine
Sleep-Apnea Solutions: CPAP Machine Dependence or Oral-Appliance Development?
Oral appliances are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.
– American Academy of Sleep Medicine(1)
The results of oral-appliance therapy are predictable when patients follow instructions and recommendations. You are more likely to wake up energized each and every morning if your body can have all the oxygen and sleep it needs.
Many cases of sleep apnea can be treated with oral appliances, but oral appliance therapy is not for every sleep-apnea case. This requires an understanding of OSA case types and treatment guidelines.
Treatment Options for Obstructive Sleep Apnea
Currently, there are four options for treating OSA, according to the American Academy of Sleep Medicine (AASM):
Continuous positive airway pressure (CPAP): CPAP is the standard treatment option for moderate to severe cases of OSA and a good option for mild sleep apnea.
Oral appliances: An oral appliance is an effective treatment option for people with mild to moderate OSA who either prefer it to CPAP or are unable to successfully comply with CPAP therapy. Oral appliances look much like sports mouth guards, and they help maintain an open and unobstructed airway by repositioning or stabilizing the lower jaw, tongue, soft palate, or uvula. They should always be fitted by dentists who are trained in sleep medicine.
Surgery: Surgery is a treatment option for OSA when noninvasive treatments such as CPAP or oral appliances have been unsuccessful. Surgical options may require multiple operations, and positive results may not be permanent.
Behavioral (and sleep-position) changes: Weight loss benefits many people with sleep apnea, and changing from back-sleeping to side-sleeping may help those with mild cases of OSA.(2)
The choice of treatment depends on the severity of the problem per your sleep-test score (AHI) and your personal tolerance and preference. As the 2006 AASM guidelines put it:
Oral appliances are indicated for use in patients with mild to moderate OSA who meet any of the following criteria:
they prefer oral appliances to CPAP therapy;
they do not respond to CPAP, are not appropriate candidates for it, or fail treatment attempts with it;
they do not respond to, or are not good candidates for, treatment in which behavior is modified, such as losing weight and changing the sleep position.(3)
AASM also recommends that OSA patients should have a follow-up sleep test, that severe OSA patients should start with CPAP because it has been shown to be more effective in severe cases, and that “oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint (TMJ), dental occlusion, and associated oral structures.”
The updated 2015 joint recommendations by AASM and the American Academy of Dental Sleep Medicine (AADSM) emphasized collaboration between sleep medicine doctors and dentists to help patients with snoring and sleep apnea.(4)
Impaired Mouth Syndrome is a set of medical and dental symptoms rooted in deficient jaws and pinched airway. It’s helpful to patients if their doctors know the dental symptoms, and their dentists know the medical symptoms of Impaired Mouth Syndrome listed in Holistic Mouth Score.
CPAP works by using pressurized air to keep the airway from collapsing during sleep, whereas oral appliances work either by holding the lower jaw (and thus the tongue) forward, or by enlarging the “three-foot cage” with oral expander appliances such as B.N.’s.
Oral appliances are “a simpler alternative to CPAP,” as a 2010 Canadian Agency for Drugs and Technologies in Health concluded.(5)
“Over the last decade, there has been a significant expansion of the evidence base to support the use of oral appliances, with robust studies demonstrating their efficacy.” according to a 2007 Australian study.(6)
In my experience, oral appliances also help to realign skeletal malocclusion and relieve chronic pain in the head, jaws, neck, shoulders, and back.
The other key to choosing between CPAP and oral-appliance therapy is patient compliance. After all, the best device or technology in the world is no good if it is not used.
A 1996 Israeli study found that, of the two, oral-appliance therapy was “strongly preferred over the CPAP by the subjects.” While both devices significantly decreased the symptoms of excessive daytime sleepiness and were broadly successful, sev
ere cases did do better with CPAP. Yet following up ten months later, the researchers found that nearly all—nineteen of twenty-one—patients continued to use their appliance either nightly or intermittently. Only one was still using CPAP. Only one was using neither.(7)
Two Categories of Oral Sleep Appliances
As I write this, there are two categories of oral sleep appliances: one-arch mandibular advancement and biomimetic expanders for 3D widening of upper, lower, or both arches.
Mandibular advancement appliances (MAA or OAm for short) are the more traditional devices. They work by holding the lower jaw in a more forward and open position overnight to keep the tongue out of the throat.
Biomimetic oral appliances (OAb), on the other hand, are similar to retainers or sports mouth guards, with bite alignment and expander features built in. Their actions mimic the 3-D growth of the jaws and the craniofacial skeleton, with a wider airway as a by-product (see chapters 15 and 16).
Both OAm and OAb come in many different designs, each marketed with different claims as to what it can do. What matters to me is not the opinion behind the device but whether it solves the patient’s problem at the root so that the body can run itself with greater ease and efficiency. Individual case reports can be useful indicators of treatment merit and clinical experience, especially when supported by science.
For instance, a 1996 study out of Canada found that oral-appliance therapy “is an effective treatment in some patients with mild-moderate OSA and is associated with fewer side effects and greater patient satisfaction than N-CPAP [nasal-CPAP].”(8)
Similarly, a controlled Australian trial by Gotsopoulos afound that over a four-week period, oral-appliance therapy for OSA resulted in “a 50 percent reduction in mean [average] AHI” and “a reduction in blood pressure similar to that reported with CPAP.”(9)
“Oral appliances are less efficacious in reducing the AHI,” says a 2006 study from University of Western Ontario “but oral appliances appear to be used more (at least by self-report), and in many studies were preferred over CPAP when the treatments were compared.” (10)
On the other hand, “CPAP produced the best improvement in terms of physiological, symptomatic, and health-related quality-of-life measures, while the oral appliance was slightly less effective,” according to a 2007 study from Hong Kong. (11)
Still, there’s a downside to consider with long-term CPAP use: It may cause both jaws to retrude in a direction unfavorable to the airway. This was the finding of a 2010 study: “The use of an nCPAP machine for more than two years may change craniofacial form by reducing maxillary and mandibular prominence and/or by altering the relationship between the dental arches.” (12)
As we’ll see in more detail shortly, retruded jaws spell bad news for the airway.
The Advantages and Limitations of Mandibular Oral Appliances
The advantage of a mandibular advancement appliance (OAm) is that the therapy is simple and relatively low cost. There are disadvantages however: it does not work in all cases, and it can create jaw-joint (TMJ) and bite issues. Moreover, it is a lifelong dependence—you have to keep wearing the device.
Clinically, long-term use of OAm can result in unintended posterior open bite where front teeth touch but back teeth do not on biting down; that may require further treatment such as braces or other dental work to restore dental occlusion. Many patients report that it takes fifteen to thirty minutes to transition from their overnight bite to their regular bite in the morning when they remove their mandibular advancement appliance. It is likely that these patients have jaw-joint (TMJ) dysfunction.
In my view, posterior open bite is rooted in the unrecognized impaired mouth. Wearing the sleep appliance overnight doubles as a TMJ therapy in these cases; i.e., it’s a treatment. So removing it actually reverses the overnight gains. This seesaw effect of OAm does not resolve the cause of their TMJ trouble or sleep apnea, even though it does serve as a useful crutch.
More importantly, both OAm and CPAP manage the airway without answering the question WHY: why does the mandible need to be pulled forward, or why is high-pressure air needed to deliver oxygen past choke points in the first place?
“Management” does not mean resolution. After using CPAP or OAm for years, the deficient airway remains. In some cases, this limitation is acceptable, such as for older patients who have mouths full of old dental work that they do not wish to change. The same limitation may not be acceptable to a college student or an adult who prefers to address the root cause once and for all.
In my opinion, leaving out the more important maxilla (upper jaw) amounts to entering the boxing ring with the dominant hand tied behind your back.
The Two-Arch and Superior Alternative: Biomimetic Oral Appliances
Enter biomimetic appliances (OAb), which can actually redevelop a narrow airway from one lane to four. This allows for more oxygen traffic as a by-product of redeveloping jaws orthopedically by restarting your own genetic assembly line to make bone. For this reason, I also refer to them as epigenetic orthopedic appliances.
“Biomimetic” means, literally, imitating life. I use biomimetic appliances to turn on craniofacial growth following each adult patient’s own genetic blueprint. I can also add features to match each patient’s needs: weak chin; snoring; crowded or crooked teeth; bad bite; jaw-joint clicks, pops, or locks; jaw clenching; teeth grinding; pain or stiffness in and around the mouth; flat midface; and/or thin lips.
Biomimetic treatment (OAb) is painless because it imitates natural growth during teenage years. OAbs can redevelop the maxilla, the mandible, or both, by:
Relaxing jaw muscles to reduce or resolve aches and pains naturally
Aligning jaws orthopedically with the head, neck, and spine
Increasing jawbone volume so that all crowded teeth fit into the dental arches, with or without braces
Creating oral volume between the two jaws for the tongue to stay in the mouth and to keep the airway open
Enlarging the airway in 3-D as a result of redeveloping both jaws and the surrounding craniofacial skeleton
ALF (Advanced Light-wire Functional) is another amazing appliance that targets both the mandible and the more important maxilla, which we will discuss in greater detail in Book 2.
Images courtesy of Dr. G. Dave Singh
Because mind, body, and mouth are connected, my oral appliance therapy is always part of an overall wellness program to bring the Whole back to higher function and better health.
By targeting the maxilla instead of just the mandible, OAb allows for a fuller expression of genetic potential in the midface and oral airway. This is a game changer as you’ll see in the next chapter.
Holistic Mouth Bites
There are many types of oral appliances. Biomimetic appliances allow us to redevelop the mouth, which in turn widens the airway. They work by signaling stem cells in tooth sockets to make new bone for the jaws.
An oral appliance is an effective treatment option for people with mild to moderate OSA who either prefer it to CPAP or are unable to successfully comply with CPAP therapy. If your AHI is less than 30, you can use oral appliances.
While appliances that hold the lower jaw forward have been shown to be helpful for OSA, they cannot come close to making a Holistic Mouth. Biomimetic appliances can by targeting both jaws.
Chapter Ten
The Rarely Addressed Game Changer: The Maxilla
The airway functions, in a real sense, as a keystone for the face.
– Dr. Donald H. Enlow,
Handbook of Facial Growth(1)
The maxilla—the medical term for the upper jaw and colored purple in the image below—forms the middle third of the face along with the cheekbones (zygoma). The maxilla is a game changer in oral and total health, yet it is rarely addressed in medicine or dentistry.
A well-developed maxilla is a cardinal feature of a Holistic Mouth while a deficient maxilla is the root of an impaired mouth. A fully developed maxilla is a secret to faci
al attractiveness AND a reliable formula to superior job performance through a wide-open airway and a good night’s sleep.
A deficient maxilla is one that’s narrow with crowded teeth, shrunken after teeth are pulled and the resulting spaces are closed by braces, retruded (retracted into the head), or some combination of these.
The big takeaway: a deficient maxilla is the origin of a narrow airway behind the palate, the tongue, or both. This has life-changing consequences as the case of Chema shows.
The Impaired Mouth that Blocked Conception: The Case of Chema
Before seeking my opinion, Chema, a twenty-eight-year-old software engineer, had gone to the hospital for pain inside her left temple and forehead and in her three upper front teeth that had undergone root canal treatment and were already crowned. After a brain scan and neurological evaluation revealed nothing wrong, the doctors suggested removing the dental work. Chema’s main complaints included pain in her upper front teeth and lower left molar, teeth grinding, jaw-joint pain on both sides, and neck and shoulder pain.
Chema turned teary when I asked my usual question: If your fairy godmother could grant you three wishes regarding your symptoms, what would you wish for? Her husband had to hold her hand as she told me between sobs about how they had been trying to conceive their first child without success.
My CSI showed that Chema had been living with undiagnosed Impaired Mouth Syndrome, including a choked airway, weak chin, crowded teeth, tenderness in both jaw joints, and cold hands and feet.
In my view, teeth grinding was the source of pain in her teeth, around her mouth, and inside her head, which stemmed from her pinched airway, which was in the orange-red zone and susceptible to collapse. Her cold hands and feet suggested possible low thyroid function and body temperature. This combination of low thyroid and pinched airway means insufficient energy to support a new life.
