Airway Obstruction - A Link to ADHD, Sleep Apnea, & Bed Wetting

A complete dental exam should always include a survey of the back of the mouth and the throat. The size and shape of the jaws, the throat, the tonsils, the adenoids, and the tongue can have an enormous influence on one's health and quality of life - especially for children. A size discrepancy in any of the above that cause complete or partial upper airway obstruction can result in a surprising number of health issues such as ADHD, bed wetting, sleep apnea, poor growth and development and poor academics. Abnormal findings discovered at an early age can lead to beneficial life altering outcomes.

A normal, healthy airway will allow air to proceed easily and quietly from the nose to the lungs (nasal breathing). As the air passes through the nose it is warmed, humidified and filtered. Nitric oxide (NO), from the adjoining sinuses, is continuously excreted into the nasal passages. NO is a potent gas and a key component for human health. With nasal breathing, NO is carried from the nose to the lungs. It is well known to relax blood vessel walls, to prevent clotting, to increase blood oxygen levels, to kill bacteria and viruses and is a strong brain transmitter (The discovery of the effect of nitric oxide on cardiovascular function won a Nobel Prize in 1998). Because of these factors, nasal breathing is presently acknowledged to be vital to good health. Any obstruction along this airway will result in a complete or partial absence of nasal breathing and cause one to breathe through the mouth (mouth breathing). But mouth-inhaled air does not benefit the lungs and the body as does nasally inhaled air. Therefore, one's health can be severely compromised.

There are many causes for partial or complete airway obstruction i.e., mouth breathing. The most common conditions that lead to mouth breathing are allergic rhinitis (hay fever), swollen tonsils and/or adenoids, deviated nasal septum and large inferior turbinates - i.e. small nasal air passages.

Allergic rhinitis, swelling of the soft tissues in the nose, is the primary contributor to airway blockage. The allergens may be inhaled and/or they may be consumed in foods. Allergies to house allergens (house dust, animal dander, etc.) will cause year round symptoms, whereas allergies to pollens will cause seasonal nasal obstruction. The more chronic the condition leading to mouth breathing, the greater will be the impact on one's health.

In children, enlarged tonsils and/or adenoids are also important causes for airway obstruction. Enlarged adenoids block the back of the nose which can result in nasal speech, post nasal discharge, coughing, vomiting, bad breath and chronic mouth breathing. The opening into the Eustacian tubes (leading to the ears), which are adjacent to the adenoids, can also get blocked causing ear aches, fullness in the ears and middle ear infections. Tonsils are located at the base of the tongue and their enlargement will also cause a physical obstruction of the airway. Large tonsils also force the tongue down and forward (in order to mouth breathe) which leads to malocclusion (bad bite), narrow upper and lower jaws and a postural change.

The nasal septum, (the wall that separates your nose down the middle) is composed of bone and cartilage. It usually separates the nose into two symmetrical nostrils. A deviated septum is one that deflects from side to side creating a large and a small nostril. Since nasal breathing cycles from one nostril to the other every 1 to 4 hours, only one nostril is open for maximum airflow at any one time. When it becomes time to breathe through the smaller nostril, partial nasal obstruction occurs. When a septum deviates from side to side and front to back, chronic nasal obstruction occurs.

Turbinates are delicate scroll shaped bones projecting into the nose from the right and left sides. There are 3 levels of turbinates and all are covered with mucosal soft tissue. The purpose of the turbinates is to clean, warm and humidify the air. If the bone or the overlying tissue is too thick, then nasal obstruction will occur.

Any obstruction that results in chronic mouth breathing can have a multitude of ill consequences for an individual. In addition to experiencing dry mouth and bad breath, the air that is inhaled through the mouth bypasses the warming, humidifying and filtering functions of nasally inhaled air. Therefore tissues are cooler, drier, and more easily infected. Also, the beneficial and protective effects of nitric oxide (NO) are absent. Blood gas studies indicate a 20% drop in oxygen levels and a 20% rise in carbon dioxide levels in mouth breathers. Therefore, mouth breathers are more easily fatigued and exhausted. This long term reduction in oxygen saturation can also lead to hypertension, a malfunctioning of the lungs and an enlargement of the right ventricle of the heart. Furthermore, snoring and sleep apnea are very prevalent in individuals who mouth breath. This disruption in sleep can result in bedwetting. This breathing pattern will also influence an individual's physical appearance. Chronic mouth breathers will exhibit postural changes (head tilted backwards), develop crooked teeth, incur deformities of the jaws and skull that lead to the "long face syndrome". These individuals are often "well below their peers in height and weight.

The signs and symptoms of enlarged tonsils and adenoids in young children can present a very confusing scenario and lead to misdiagnoses. Adenoids grow from 6 months to 2 - 3 years old and occupy about 50% of the throat area behind the nose. Swollen tonsils cause the tongue to move down and forward, and the head to tilt back in an effort to breathe. Enlarged adenoids and tonsils are the primary reason for snoring and sleep apnea in children. Research at the University of Michigan has indicated that a child who snores regularly is four times more likely to exhibit symptoms of ADHD. An obstructed airway at night will reduce the amount of oxygen that gets to the brain. The consequences may be disturbed sleep (moving violently), problems waking up, being easily fatigues, getting morning headaches, and exhibiting daytime behavior problems that might include irritability, hyperactivity and being easily distracted. One study even found that a child who snored was more likely to exhibit poor academic performance in middle school. These children are often misdiagnosed with ADHD and placed on stimulant drugs such as Adderal or Ritalin.

An obstructed airway also can lead to bedwetting. If a child has been toilet trained and suddenly begins bedwetting again then it may be due to an obstructed airway. When a child with breathing problems finally falls asleep, the sleep is so deep that they lose bladder control.

All of these health problems can usually be eliminated by correcting the airway obstruction and establishing good nasal breathing. Removal of tonsils and adenoids will almost, 90% of the time, cure sleep apnea and therefore eliminate all the related health issues and behavioral problems. 75% of all tonsillectomies and adenoidectomies are performed to correct airway obstruction.

Where the airway obstruction is caused by allergies then referral to an allergist should be made. If the above are not found to be responsible for the mouth breathing, then referral to an ENT is necessary to evaluate the nasal septum and turbinates.

When the obstruction to nasal breathing is corrected by medication (for allergies) or surgery (other physical obstructions), the individual may still continue to mouth breathe. In order to breathe nasally, the tongue must be positioned in the roof of the mouth. But, in cases of chronic obstruction, the individuals wind up with narrow and small jaws. If the upper jaw is too narrow, the tongue will not have enough room to rest in the roof of the mouth and mouth breathing will continue. Functional orthodontics is then required to expand the jaws and create a resting place for the tongue. When the tongue is positioned in the palate then mouth breathing cannot occur. In some cases, myofunctional therapy is also necessary to retrain the tongue (once there is adequate room) to rest in the palate so that nasal breathing can easily occur 24/7. After all, nasal breathing is the main goal and is an absolute necessity for achieving good health and a long productive life.