By Steve Carstensen, DDS 

Patients come to our dental offices with some common complaints related to poor breathing and oral inflammation…dry mouth…bad breath…gingivitis…excessive wear on teeth. They ask us to help them.  

One of the things we can do for our patients is to be curious about whether they have intermittent hypoxemia that is diagnosable and treatable. I caution us to be aware of having too narrow of a focus. When someone presents with jaw pain, wake-up headaches, and tooth wear, we tend to think they need a supporting nightguard. I think we should be curious about what else might be going on. 

I ask my patients about snoring. I ask them if they have been diagnosed with a breathing disorder. I wonder if they should be using CPAP before I make a bite splint. If you make a splint, they may come back and report they don’t like the splint, which may be because it interferes with their breathing. So, I recommend we stay curious, and when we do make a protective guard for their teeth, we ask more questions. Make sure the diagnosis we make not only correlates with the symptoms, but the patient responds well to the treatment we provide.  

How can we help our patients’ breathing physiology? We can help them be better breathers. There are oral appliances that keep the jaw from falling back and crowding the airway but what about the daytime? It turns out that people who breathe “badly” during the day develop breathing behaviors that the brain continues during the night, and these behaviors are inefficient for keeping the airway open during sleep. So, if we help our patients breathe better in the daytime, we set their brains to be more capable of handling airway disruptions during sleep.  

If you’ve read the book Breath by James Nestor, you will learn about the daytime problems translating into nighttime problems and that nose breathing is best for our physiology. I am a huge nose breathing fan. There are electrical signals that pass from specialized cells in the nose directly to the limbic system which influences our autonomic nervous system. It filters sensory signals from the rest of the body and sends proprioceptive signals into the cortex and down into the autonomic nervous system. None of these brain-signaling signals happen with mouth breathing. 

If you ask someone, “How is your nose breathing?” They will say, “Fine,” because you are the dentist, and they think that is a strange question. They also are accustomed to the amount of work it takes to breathe through their nose, so they don’t really know if they breathe through their nose well enough. The way to test is to ask them to close their lips and put their finger over their lips for two minutes and breathe calmly. With the finger over their lips, they are unlikely to have difficulty breathing through their nose but if they start breathing faster this is a sign of stress. If their heart rate goes up, if they know it was tough for them to do, there is something interfering with their nose breathing. It might be a deviated septum, allergies, a head cold or chronic rhinitis—but something is wrong.  

Knowing this is handy when we are planning to do restorations. You won’t use a rubber dam if they can’t breathe through their nose, or you will schedule to do the restorations after they’ve been medicated. I have found that Afrin is good for clearing the nasal passages before dental treatments. Short-term help is good but stay curious about how often they cannot breathe through their nose, and help them. 

By Steve Carstensen, DDS 

I want to share a clear example of how bad sleep directly affects the anatomical structures dentists pay a lot of attention to—the mandibular condyles.  

Sleep Disruption Disrupts Bone Regeneration 

We’ve all seen on X-rays condyles that do not look healthy. We wonder what causes so much degeneration. There are shelves of books and whole courses about what goes wrong but one of the things that affects condyles is a circadian rhythm disruption. Research* with rats has demonstrated that sleep disruption disrupts bone regeneration, causing thinning of the condyles. 

* Corrigendum: Circadian rhythm protein Bmal1 modulates cartilage gene expression in temporomandibular joint osteoarthritis via the MAPK/ERK pathway. Chen G, Zhao H, Ma S, Chen L, Wu G, Zhu Y, Zhu J, Ma C, Zhao H.Front Pharmacol. 2022 Sep 8;13:971840. doi: 10.3389/fphar.2022.971840. eCollection 2022.  

Rats were interrupted from their sleep cycles so they could not get through a normal night’s sleep. After eight weeks they took the disruptions away. During the first four weeks the cartilage layer over the condyles thinned, became really thin at six weeks, and stayed that way across eight weeks. After they returned the rats to undisrupted sleep for four weeks, the breaks in the normal covering of the condyles were still there.  

What do we take from that? The earlier in life that we establish healthy physiology that supports healthy sleep, the greater the chance children have of growing human condyles to withstand TMJ problems later.  

Disrupted Sleep Contributes to Multiple Health Issues 

There’s a lot of research that points to poor breathing contributing to pediatric and adolescent health issues. Among these issues are neurological deficits, behavioral problems, poor school performance, and pulmonary hypertension. A primary cause of poor-quality sleep among our youngest patients is enlarged tonsils and adenoids that obstruct their airway.  

Helping Children and Teens Breath and Sleep Better 

What can dentists do in daily practice with children and teens to help them breathe better and sleep better early in life?  

1. Educate our adult patients who are parents of children to be aware of signs and symptoms.  
2. Develop a culture within our practice of being a health consultant, so our adult patients feel welcome to easily engage in conversations about health issues that commonly affect children and teens.  
3. Introduce the parents to their own need for an open airway for healthy sleep to raise awareness.  
4. Assess all our patients for breathing issues and examine their airways for signs of obstruction.  
5. Provide guidance to our adult patients and to the parents of the young people in our care so they can choose appropriate care.  

Our Responsibility 

We need to start paying attention to these things as much as we do the health of the teeth and periodontium. As dentists, we are responsible for the entire cranial facial respiratory complex. My colleague, Dr. Kevin Boyd in Chicago, is a pediatric dentist who came up with that label a few years ago. I love that term, because it helps us focus on the whole person, structure and function! We can be proud when we help our patients with the respiratory part of the complex. 

As we take our place in medicine as being in charge of the cranial facial respiratory complex, we get to affect growth and development. We get to help train the body to swallow properly and grow good bone and good airway support. And that’s the major role I think dentists are going to have going forward in healthcare–identifying those children who have an underdeveloped cranial facial respiratory complex and influencing their care. Like other folks in medicine…an ENT doctor…a myofunctional therapist…a speech therapist, we help correct the things that we recognize that are going wrong. 

By Steve Carstensen, DDS  

“Hypoxic burden” is the challenge that the body has to low levels of oxygen on an intermittent basis. Our physiology has an adaptive capacity to manage hypoxic burdens. We can hold our breath. We can dive under water. We can go up in an airplane. We can live at different altitudes. When that adaptive capacity is exceeded, low oxygen places our physiology under stress. At the extreme level, organs are injured. Frequently occurring or sustained hypoxic burdens at lower levels lead to chronic disease conditions. These are chronic non-infectious diseases of inflammation. 

As people sleep most keep their airway open. Whether they are on their backs or on their sides, they have an open airway and breathe through their noses. But 29 millions of us in the United States have some form of obstruction in their airway while they sleep. The general term for all levels is sleep-related breathing disorders. At the most serious level we call it obstructive sleep apnea. 

Many of our patients have daytime breathing problems as well but during sleep a large percentage of our patients have intermittent hypoxia because their tongue occludes their airway and their oxygen levels drop. The brain kicks in when the body exceeds its adaptive capacity and wakes the patient up. Their physiology is under stress. They are not getting a restful night of sleep.  

The Size of the Problem 

Millions of people have some form of sleep related breathing disorder. The American Academy of Sleep Medicine commissioned Frost & Sullivan to do a study in 2016 that calculated the annual economic burden of undiagnosed sleep apnea among U.S. adults as approximately $149.6 billion (about $460 per person in the US). The estimated costs included $86.9 billion (about $270 per person in the US) in lost productivity, $26.2 billion (about $81 per person in the US) in motor vehicle accidents and $6.5 billion (about $20 per person in the US) in workplace accidents. There is no dispute about the size of the problem, but even the best efforts of dentists working in tandem with sleep physicians have not addressed the volume of people who would benefit from care. 

Currently there is a shortage of Sleep Medicine specialists. The recent approximation is 7,500 but not all are practicing. Even if there were 10,000 diagnosing physicians, it is a small number compared to 193,000 practicing dentists. There is a consensus of leaders in the field who think there are a few thousand dentists actively treating sleep-related breathing disorders, but maybe only a few hundred delivering a significant number of devices per year. There need to be many more. We can incorporate airway assessment and patient education into our workflow to support the breathing and airway health of our dental patients. We can add more services to our practice mix to address their needs within our licensure. So, I am on a mission, if you will, to take this challenge to my Pankey Institute colleagues through a series of blogs and educational opportunities, starting here and in presentations during the Essentials continuum. 

The Consequences of Sleep Fragmentation 

During a normal night’s sleep, we’re supposed to go through cycles of light sleep, deep sleep and dream sleep (REM sleep). If you have a new baby, a new puppy or breathing disorders and your sleep is interrupted frequently because of these things, you’re not going to get a good night’s sleep. When fragmented sleep is created by a breathing-related sleep disturbance, we have cycles of apnea and arousals—intermittent hypoxia that leads to health problems.  

Our patients may not call it sleep fragmentation. They may say I get terrible sleep. If they are not able to breathe well through the night every night for decades, there are pathophysiologic consequences. The worst are systemic inflammation, adrenergic activation, and oxidative stress. If the human body responds to chronic intermittent hypoxia after the adaptive process is exceeded, the body starts to break down. Manifestations include insulin resistance, hypertension, Type 2 diabetes, heart failure, atrial fibrillation, stroke, non-alcoholic liver disease, chronic kidney disease, cancers, and polycystic syndrome.  

The respiratory system manages gas exchange in our bodies. It is the foundation of our physiology. We disrupt that and we allow the body to develop these other issues. Our patients complain they have had difficulty having these diseases diagnosed and treated. But now we have ways to intervene to prevent these problems upstream. We can do that as dentists.  

Breathing and airway support is a powerful place for dentists to impact the whole-body health of those we serve. 

By Mary Osborne, RDH 

How much time do you schedule for a new patient, non-emergency visit? Is your priority efficiency or effectiveness? Is your goal to gather as much clinical data as possible, or is it to begin to build a relationship of mutual trust? Both are possible if you see the new patient visit as more of a process than an event.   

Too often new patients are rushed through an assembly line: brief conversation, clinical exam, diagnostic records, and treatment presentation! Is that really the best way to help people make choices about their health?  

There is no one right way to schedule a new patient. Different practices are successful with different models based on the values of the practice, practice growth, and the personality and skills of doctors and team members. The most important determinant of success is our ability to meet each patient where they are and join them on a journey to health. I am not suggesting we should be without practice standards of care.  We have a responsibility to decide what we need before beginning treatment. Our challenge is to guide patients to understanding why we need what we need, and why that is relevant to their unique situation.   

We may anticipate that patients will resist this type of experience, but if we make it truly about the patient and are flexible, I have found that patients are more than willing to participate in an individualized process that best meets their temperament and circumstances. 

I remember seeing a new patient that I was told was a “very busy attorney” because his secretary said so when she made the appointment and his wife said so when she confirmed the appointment. I anticipated that he would be a driver and prepared to efficiently move him through his appointment.  

As I explored his health history with him he expanded on the specific answers to questions. Soon, he was leading the conversation. When I remarked that I wanted to make sure we were making good use of his time. He said, “Mary, what’s this about time?” I replied that I knew he was very busy. He said, “Mary, this is about me. I have time for me.” 

His statement has stayed with me because I realized that if the conversation had been about me going through my check list and not listening to him, it would not have been a worthwhile experience for him. It also wouldn’t have been a worthwhile experience for me. 

I have learned that when the patient feels in control of the process they are willing to give that time to themselves. A lot of aha moments occur as they learn about themselves while speaking. When patients feel like they are on an assembly line being moved through our system, they have every right to be resistant.  

Empowering patients to lead the process is both an attitude and a learnable skill. When we can lose ourselves in the moment, really listen, really encourage, and really care about the patient’s thoughts and feelings, it is easy to make connections to the next step we recommend.  It is my experience that I can more quickly become a trusted health advisor when I intentionally share control with my patient. 

Most patients are willing to invest more time in the process when they see the connection between their needs and what we recommend.  These are typically patients who have or have had complex health issues and are seeking to improve and retain health. They perceive the value of the extended process and how much value you place on spending in-depth time with them.  

The entire team’s communication can deliver the message that everyone in the practice is keenly interested in them, and their appointment is uniquely planned to meet their needs.  

What has been your experience? Are you open to scheduling more time for conversations that typically garner trust and appreciation earlier in the relationship? 

By Mary Osborne, RDH  

The questions we ask on a health history form have more to do with disease history than health history, right? The focus is on disease right away. I like to shift that focus to health by saying, “I see that you’ve filled out this history and I’d like to talk to you about specifics, but I wonder if we can begin by you telling me a bit about your health in general? How healthy do you think you are?”  

I have found that if I start with health, I’m more likely to have a patient talk about health. If a patient says, “I think I’m pretty healthy,” I can ask, “What do you do to take care of yourself?” I can relate by acknowledging that I am trying to take better care of myself and how it isn’t always easy. Or I can pick up on something that is important to the patient, such as a concerted effort to get enough sleep or stick to healthier foods or to bicycle many miles a week. I can say, “Tell me more about that. It sounds like you feel better when you do that.”   

The questions you ask shape the conversation. And by the way, that does not just apply to reviewing a health history with new patients. It applies to every single interaction, with every single patient, with everyone on the team.   

When someone comes for their routine hygiene check, I might ask about their recent vacation or how their kids are doing, but I also always ask questions that open a conversation about health. Instead of starting with, “Have there been any changes in your health history since I last saw you?” I like to ask, “How has your health been since I last saw you?” Instead of asking, “Have there been any dental problems that you want us to pay attention to,” I ask, “What have you been noticing about your teeth recently? What are you noticing when you brush or when you floss?”  

We have to deal with disease. That’s a part of our job but moving toward health is more enriching. It’s positive.   

If you want to be seen as a partner in health, then moving the conversation in the direction of health is much more powerful than focusing on disease. The truth is everyone has a personal health story. There are things they are happy about and things they are sad about. When we take a little time to explore that story with questions, we and our patient gain insight into their experiences, attitudes, and feelings about their health. We and our patient get a better understanding of their motivations and the strategies they employ to become healthier. If we invite them to share their perspective with us, they will be more willing to hear our perspective, and we can extend an invitation: “Would you like to hear my perspective about that?”  

I recognize that inviting and engaging the patient in expanded conversations about their health may take a little more time, but it is effective time. Over the years, I noticed that when I thought I was being most efficient, I was generally being less effective. And in the long run, I ended up spending more time understanding what the problem was and trying to give more information without getting enough feedback to know if I was being heard or influencing the patient.   

One of my favorite things to hear from a patient is “You know, I never thought about that before.” I remember a woman who told me that she had been a smoker, but she had quit smoking. And I asked her how she did that. What prompted her? She said it was when her daughter was born that she realized that she didn’t want the smoke around her daughter. In her health review and preclinical conversation, she mentioned one of the things she did for exercise was tap dancing lessons, so I asked her how she got into that, and she said, “I figured I could spend time with my daughter, get exercise myself, and set a good example for my daughter. Wow, I guess my daughter is really a good influence on my health, isn’t she?” 

Those are the light bulb moments that light up my day.  

By Mary Osborne, RDH  

The late Dr. Bob Barkley said your dental degree gives you the right to practice dentistry, but you have to earn the right to influence your patients. How do we earn the right to influence? How do we get that invitation we need to be invited into influence? 

There is a powerful tool you already have in your practice that can enhance your relationships from the initial visit through continuing care: a Health History. The Medical History forms most offices use are designed to efficiently gather information from patients about existing and previous conditions and diseases. Patients quickly check boxes. But it can do so much more. If you use health histories as opportunities to begin a dialogue with your patients you can also connect with them in the context of a mutually interesting topic — their health! 

I might begin a conversation with a new patient by saying “In this practice we believe that the health of your teeth is related to your overall health. I know you filled out this health history form and we can talk about the specifics of that, but I wonder if we could begin by taking a few minutes for you to tell me a little bit about your health in general.” Beginning with a conversation in that way it takes us out of focus on disease and opens the door to talking about health; what they know about their health, how they feel about it, and what they do to maintain health. Similarly, when a patient comes in for a hygiene visit instead of asking if there are any changes in their medical history, I might ask, “How has your health been since I saw you last?”  If we listen carefully to their stories about health, we will gather important clinical data, and we will also begin to understand their values. We will begin to co-discover what is important to them. 

The concept of co-discovery is frequently seen as having to do with helping the patient see current clinical conditions that we see. In that way, it’s a very useful tool. But I’d like you to begin to also think about co-discovery as a way of being in relationship with your patients. When you take a few minutes to have a dialogue about health you learn about your patients, as they learn about themselves. It is an opportunity for you to learn about their experiences, concerns, and perceived barriers to health—and it’s also an opportunity for patients to learn about themselves. 

In her book, “Kitchen Table Wisdom,” Dr. Rachel Naomi Remen says, “When you listen generously to people they can hear truth in themselves, often for the first time.” If you’ve had a conversation like this you know the magic that occurs as a patient realizes things about themselves they’ve never thought of before. As they speak out loud they hear themselves for the first time. I have found that if I show up as an understanding fellow traveler with a desire to learn, it opens the door for them to begin to see me as a trusted advisor.