Any interference of the air intake, whether it be through the nose or the mouth alters the important exchange of oxygen for carbon dioxide to the lungs and can seriously affect the neural (brain), endocrine and immune systems and alters the general health and well-being of an individual. In a study of 464 children, from 4 to 13 years of age who visited their dentist to have their teeth checked, and who all had no knowledge or interest in sleep issues, were given a sleep severity questionnaire for their parent to fill out. This study indicated that 92% had abnormal sleep issues with a mean number of 7.7 symptoms per child with a mean severity of these symptoms of 16.8 which indicated an Index of 24.5 (7.7 + 16.8 = 24.5 Index). This is represented as a Grade 3 severity with recommended treatment of their abnormal sleep disordered breathing issues. This result indicates that 9 out of 10 children have serious abnormal sleep conditions, and only 1 out of 10 can be considered to have normal nasal breathing with no indication for treatment. If abnormal sleep is so common, and the results of treatment avoidance are. so critical, what effects can this have on the health and normal development of children and even long-term effects into adulthood?
In an analysis of 501 children, 2 to 19 years of age (Stevens BA, 2016) found that 93% of 27 of the most common symptoms of abnormal sleep, do not self-correct and 30% actually increase in severity from 4 to 12 years of age. In another study of 1034 children from 4 to 13 years of age (Bergersen, 2021), it was found that Nighttime Mouth Breathing (NMB) has the greatest incidence of 32 symptoms studied, being at 69%, while abnormal nasal breathing was present in 21%. This would indicate that NMB which involves only oropharyngeal issues, represents 77% of abdominal breathing problems, while Abnormal Nasal Breathing (ABN) which involves the nasopharynx represents 23%. In this same study, it was found that 84% of children with abnormal nasal breathing also mouth breathe at night, with an index of NMB of 41. The children that had ANB with no NMB present had an incidence of 16% with an Index of 18. This indicates that about 69.5% of the Index represents oropharyngeal effects, while 30.5% represent nasopharyngeal issues. This is another way of saying that the oropharynx issues represent about 73% (77+ 69.5 = 146.5 / 2 = 73.3%.) of the total breathing problem, while the nasopharynx represents about 27% (23 + 30.5 = 53.5 / 2 = 26.8%).
The above representation should not be interpreted that nasal obstruction is not important and can be ignored regarding treatment procedures. Actually, difficult nasal breathing has an occurrence of 22.3% and impossible nasal breathing represents 0.7% and both have a significant impact on the occurrence of NMB, being that ANB has 32% more NMB than where NMB is present in normal nasal breathing. In other words, ANB has a 32% impact on NMB over the amount of NMB that is normally occurring in normal nasal breathing patients. The conclusion from this statistic is that one must treat abnormal nasal breathing in order to reduce the NMB by about 32%, since this is the increased impact that ANB has on NMB, as well as also treating the NMB since it represents 57% incidence without the effect of ANB. To treat either one without the other would not be expected to completely eliminate or maximally reduce a breathing problem.
The advantage of the Habit Corrector appliance is that it eliminates the patient’s ability to mouth breathe while at the same time forces normal nasal breathing to occur. It is not recommended to use the Habit-Corrector® appliance in impossible nasal breathing patients until an ENT assessment can be made as to the cause of such a problem.
A frequent solution for a constricted airway is the use of a rapid palatal expansion appliance (RPE) for the correction of a posterior cross bite, if present, together with a mandibular displacement with a lower midline deviation to the side of the more normal occlusion that does not involve the cross bite. Activation of this appliance opens the midline suture of the palate which not only corrects the cross bite, but also improves the midline issue and mandibular shift by widening the maxillary arch. At the same time, this enlargement of the maxillary arch increases the nasal cavity and usually restores the impossible breathing issue unless the cause is due to adenoidal tissue swelling. One of the major problems of this RPE appliance is that it does not correct oropharyngeal issues which are also usually present. In such cases where an RPE appliance is being used to improve nasal breathing, it is also recommended that a Healthy Start Habit Corrector is used at the same time while sleeping.
There are various causes of difficult and impossible nasal breathing which involve about 25% of the population of children. Adenoid swelling, deviated septum, allergic rhinitis, polyps, cysts, and enlarged turbinates are all possible causes for abnormal nasal breathing. Adenotonsillectomies are estimated to correct about 25% of apnea issues, while the Habit Corrector appliance can correct 70%. According to research, correction of NMB has 81.4% more success in correcting apnea than ANB correction alone.
Further results from this same research found that NMB is more closely associated with the following issues than abnormal nasal breathing on its own; overjets > 7mm, bruxism, pacifier use >12 hours / day, abnormal swallowing, maxillary arch width narrowing, apnea, hypopnea, daytime mouth breathing (DMB), ADHD, speech, severe snoring, headaches, poor school performance, wakes up at night, attention deficit, bedwetting, restless sleep, and the Severity Index amount.
Nighttime mouth breathing should be considered as a habit, since it can be corrected by myofunctional therapy and it is also easy to become a habit if a child has frequent nasal rhinitis issues with a partially or blocked nasal airway. Daytime mouth breathing does not produce the deleterious effects on the several symptoms that NMB does, because the various muscles that prevent the mandible from displacing posteriorly during sleep are not in a relaxed resting state during the day. As a result, there is no posterior impingement during the day from the base of the tongue against the oropharynx due to the relaxed state of the pharyngeal dilator muscles at night that relax during sleep and as a result, the pharynx is more able to be narrowed by the posterior displacement of the mandible and base of the tongue during sleep.
Abnormal nasal breathing has a statistically significant effect on both the severity (P=0.001) and incidence (0.001) of DMB, however, NMB has a greater effect on the severity (0.001) and incidence. (0.005) of DMB over ANB (with no NMB present). In other words, NMB plays a greater significant role in the presence of DMB compared to the effect of ANB alone. There appears that there is a very close relation between DNB and NMB and such as the significant correlation P=0.01) between the two indicating that changes in the severity of DNB is directly related to the severity of NMB. If a patient has a severe problem with DNB, which is easily identified, they will also probably have a severe problem with NMB. Since NMB is a greater health risk to a patient than DMB, it is very helpful to know that this significant correlation exists when one might not be aware of the nighttime habit’s severity. The best age to assess and treat these abnormal nasal and mouth breathing issues is before a child enters school.
Nighttime Mouth Breathing directly impacts behavioral and neurocognitive issues such as problems making friends, personality problems, daytime irritability, attention deficit issues, poor school performance especially in math, spelling and science, hyperactivity, and daytime sleepiness. ADHD (attention deficit hyperactivity disorder) occurs in 23% of children, and 50% of those with this problem are held back one year in school, and 30% are held back two years, parents often thinking that children with this problem will obtain improvement with increasing age which does not happen. In fact, 50% of these children with ADHD have substance abuse problems in their teen years. Corrections of this problem at an early age results in 40% mean improvement in hyperactivity, 42% in attention deficit, and 37% in ADHD. Those same symptoms obtaining 100% correction obtain 26%, 24%, and 14% respectively, within a period of 6.4 months of Habit Corrector appliance wear.
The highest mean corrections obtained with nighttime wear of the above appliance are A.M. headaches (91%), snore at all (80%), apnea (79%), habitual snoring of 5 to 7 nights per week (78%), hypopnea (76%), bluish color at night or days (69%), bruxism (68%), and nighttime mouth breathing (65%), while the mean of all of the 27 symptoms studied is 59%. Of those experiencing correction which totaled 75% had a mean improvement of 76%.
Certain symptoms that are strongly associated with nighttime mouth breathing being present in 69% are snore at all (64%), wakes up at night (54%), daytime sleepiness (49%), bruxism (47%) and restless sleep (46%). There are other symptoms that are not so important in their relation to NMB for a child’s well-being, but have a high incidence are hard time listening and often interrupts (58%), talks in sleep (57%), daytime mouth breathing (54%), fidgets with hands and other tics (45%), allergies (45%) and excessive sweating at night (39%). Any child who mouth breathes at night and who also snores will usually also have symptoms of restless sleep, frequent waking up at night, experience daytime sleepiness and bruxism usually also have serious sleep issues.
A helpful diagnostic analysis is the Sleep Severity Index which is determined by adding together the number of symptoms present plus their severities and results in an accurate gauge of normal and abnormal sleep and consists of five grades of severity. This Index has a severity range of 0 to 100, with Grades 3 (consisting of 20 to <45), Grade 4 (consisting of 45 to <70) and Grade 5 (consisting of 70 to 100), all considered to be serious enough to warrant moderate to strong recommendations for treatment.
The seven most important symptoms with their mean respective treatment improvements over a period of 6.5 months of treatment are nighttime mouth breathing (65%), snore at all (63%), daytime sleepiness (58%), wakes up at night (55%), daytime mouth breathing (53%), restless sleep (51%) and bruxism (68%) all of which represent a total mean treatment success of 59%. Those having treatment improvement during this 6.5-month treatment period consists of 77% of the total sample of N=220 with a resultant mean correction of 74%.
Another important fact is that when the oxygen intake is reduced in developing children, it directly impacts the endocrine system which is responsible for producing a hormone that decreases the size of neurons in the brain during sleep, while increasing the size of these neurons during the waking hours of the day. Brain activity during the day produces a toxin called beta-amyloid which is deposited between the enlarged brain cells and at night the endocrine system produces a hormone that reduces the size of the brain cells which increases the intracellular space thus allowing such toxins to be easily eliminated by the intercellular fluid during sleeping hours. When a serious sleeping condition is present, lack of oxygen reduces the hormone that is responsible for reducing the brain cell size at night which allows the enlarged daytime brain cells to remain during sleep which prevents the elimination of the beta-amyloid toxins. It is thought that the accumulation of beta-amyloid over a lifetime may be responsible for dementia and Alzheimer’s disease in later life since these two later life problems have increased amounts of this toxin between the brain cells. Also of importance is that adults who have serious sleep issues almost always report that they had sleep abnormalities as children. Health problems that are most associated with adult sleep disorded breathing issues involve cardiovascular abnormalities such as high blood pressure, atrial fibrulation, heart attacks, stroke as well as diabetes and excessive weight.
