By Steve Carstensen, DDS 

The following four exercises will support your physiology. As you practice them during the day, your nighttime breathing will improve. These exercises are not a cure for snoring or sleep apnea but any improvement in respiratory patterns helps day and night. 

Light Breathing  

Our brains are sensitive to the oxygen and carbon dioxide balance in our blood. The buildup of CO2 triggers respiratory cycles. As we breathe lightly, we increase our brain’s CO2 tolerance. If we are sensitive to hypercapnia, we breathe faster. Quicker breaths lead us into poor gas balance.  

Imagine there is a string in the top of your head pulling it towards the ceiling. Your posture is straight. Now close your lips so you are nose breathing. Breathe as lightly as you can so you barely feel the air moving through your nose for two minutes. Don’t concentrate on how deep you breathe. As you do this you will wish you could breathe a little more. That’s called “air hunger.” As you do this exercise more, the air hunger will fade. You are changing your body’s CO2 tolerance.  

Increasing the amount of CO2 our brain allows us to maintain helps our blood release more oxygen to our cells. Blowing off too much CO2 starves our cells of the oxygen they need for health.  

Deep Breathing  

The next exercise is called “Breathe Deep.” We have two different major muscle groups that fill our lungs. The primary one is the diaphragm, the secondary one is the intercostal muscles of our chest, between our ribs. Diaphragmatic breathing—breathing deep with your diaphragm, produces physiologic benefits. The increase in intra-abdominal pressure increases gut motility and activates the back and pelvic muscles to stabilize your core. This strengthens good posture.  

Sit up or stand straight. Place your hands on your sides so you feel your last two ribs. Breathe slowly and lightly. Feel those two ribs expanding. The diaphragm attaches above these ribs, so the muscles are not moving the ribs; the intra-abdominal pressure is pushing out on those ribs. Now breathe through your nose deeply so you can feel those ribs expand. Do this for two minutes. You might feel a bit of air hunger during this exercise as well.  

Slow Breathing  

The third exercise is “Breathe Slowly.” This is a cadence or timing exercise issue. As you breathe lightly and you breathe deeply, you breathe in for a count of four, hold it for a second, breathe out for a count of six, hold it for a second, and then repeat the cycle of in for four, hold for one, out for six, and hold for one. This will add up to six breaths per minute, which is the best for health because it calms the autonomic nervous system and sends the right signal to the vagus nerve and the rest of the nervous system. You can fit this into your day between patients to calm down and focus better.  

Control Pause Breathing  

The “Control Pause” breathing exercise measures the number of seconds you can comfortably hold your breath after exhaling and is an indicator of how well you breathe. Athletes can go as long as 40 seconds. You might be able to go 15, and that’s okay because this exercise, practiced over time, will improve your breathing volume.  

Breathe in through your nose, exhale, and then pinch your nose. Wait for your body to tell you when to breathe. This is not the very first indication, nor is it a ‘breath-holding contest.’  When you are aware of the signal, breathe normally again for ten seconds, pinch your nose again, and hold. By practicing this pattern for three minutes, over time, you will see you can pause your breathing longer and longer. The number doesn’t matter. The effect you have on the number with practice does matter. If you aim towards a pause of 30 to 40 seconds, you can achieve great breathing health and athletic fitness. It’s another way of increasing your CO2 tolerance, providing more oxygen to your cells.  

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. 

I heard about the new Inspire sleep apnea device over a year ago. If you have not heard of “Inspire” yet, be on the lookout. TV commercials are everywhere.

What is Inspire? It’s an implantable device that helps treat sleep apnea. Much like a pacemaker, a surgeon implants a little control device with some electronic leads to manage neural inputs to the muscles around the airway in order to help hold the airway open.

After the device is implanted, the patient presses a button on a smart device app to turn it on and off. It’s as simple as pressing the button when they are ready to go to sleep and pressing it again when they wake up. There is no need to wear a CPAP or oral appliance.

Over a year ago, when I first learned about Inspire, I mentioned it to a patient who had already had orthognathic surgery, had tried CPAP, and was still struggling with his quality of life while dealing with OSA. He was tired of having a dry mouth and increased risk of caries. We had already had several conversations.

At a subsequent appointment, he shared with me that he was extremely grateful we had had that conversation about Inspire. It motivated him to talk to his primary care physician and look at having the device.

He also shared with me that this treatment was covered by Medicare and then his gap insurance. Why did they cover it? Interestingly, it was not because he was CPAP intolerant or he had failed—because he was regularly wearing his CPAP. They covered it because he was suffering dental decay, dry mouth, and other secondary issues due to the CPAP.

I think we’re going to hear about this device more from our patients, and there will be times when we think it is in our patient’s best interest to start a conversation about it. If you are not familiar with Inspire, I recommend that you hop on the Internet and learn more about it.

Interested in Learning More About Dental Sleep?

Course: Creating Healthier Patients & Practices: Integrative Dental Medicine
Date: August 11 – 12, 2023
Location: The Pankey Insititute | 1 Crandon Blvd Key Biscayne, FL 33149
Register: Click Here

Screening our patients for airway and breathing issues is becoming a standard in dentistry. One of the things we have started to do every day in our Hygiene rooms, with our patients from three years old to very elderly, is visually looking at the back of their mouth and assign a Mallampati score.

The Mallampati score was developed by anaesthesiologist Seshagiri Mallampati, in 1985, as a non-invasive way to assess the ease of endotracheal intubation. The test is simply a visual assessment of the distance between the base of the tongue and the roof of the mouth.

In our practice, we begin a conversation about airway with patients. The Mallampati diagram (see below) allows both us and our patient to visualize, on a score of 1 to 4, the patient’s anatomical airway. We laminated the Mallampati diagram off of Google Images, and we can give it to the patient to hold while we screen them, or we share it with them after screening to let them see why they received the score they did. We then continue the conversation with them about their airway and why it might be a good idea for them to observe sleep patterns or be referred to a sleep physician for further diagnosis.