Barry Raphael, DMD, combines the goals of traditional orthodontics with teaching breathing habits that counter the effects of the Western lifestyle.
At the Raphael Center for Integrative Orthodontics in Clifton, NJ, founder Barry Raphael, DMD, believes treatment for obstructive sleep apnea (OSA) needs to begin early in life and that, when applied appropriately, preventative measures can greatly reduce the severity of sleep disturbance symptomology or avoid its appearance altogether.
As an orthodontist, he believes the ideal outcome includes straight teeth and good breathing habits. The appearance of crooked teeth, he says, “is not genetic but instead a reaction to foods and environment of the modern world. Small jaws mean less room for the teeth and so they come in crowded. What’s worse is that the space behind the jaws—where air passes from the nose to the lungs—is also getting smaller,” Raphael says. “This is a modern epidemic, and it parallels many of the other chronic diseases of the Western lifestyle, like diabetes, heart disease, and many more.”
Antecedent factors underlying the development of disordered breathing include the size and collapsibility of the airway and the velocity and turbulence of the airflow. Although the role of genetic influences on the presentation of these factors cannot be ruled out, Raphael notes, anthropological evidence points to rapid changes in dietary, early-life weaning and feeding, postural, and sleeping behaviors associated with modern styles as being significant progenitors to these determinant factors.
“OSA is the end stage of a long process that begins before birth. By helping children grow with full-sized jaws, they will also have the biggest, healthiest airway. In this way, there will be less snoring, less limitation to air flow through the airway, and, hence, less obstruction as well.”
Raphael says intervention requires practitioners and patients to first reverse bad habits, such as breathing too fast and breathing through the mouth, then undo the damage those habits have caused. Treatment that improves jaw and airway growth in addition to the development of better breathing and postural habits is essential, he says, and should be put into practice as soon as habits which lead to poor facial growth are discovered in younger patients.
“By the time you have obstructive sleep apnea, you have been breathing poorly for a long time. Not everything can be reversed,” Raphael says. “But just like rehab from any chronic ailment, lifestyle changes can reverse some and delay the progress of other symptoms, in this case, of bad breathing.”
Patients who appear to be at risk should be encouraged to practice the “competencies” that lead to better breathing and sleep:
- Breathe gently through the nose
- Keep the lips together when not talking or eating
- Rest the tongue on the palate
- Swallow without using the facial or cervical muscles
- Maintain good posture to avoid straining those muscles
- Eat nourishing, not “challenging” foods
- Get enough restorative sleep
- Manage chronic stress by breathing properly throughout
For adults who are already suffering from advanced OSA, Raphael says, losing weight is no longer the only course of action available. Adopting as many of the habits listed above will likely lead to a reduction in the severity of their symptoms and improve sleep.
An integrative orthodontics practitioner is not the last line of defense, he adds. Depending on the patient, otolaryngologists, allergists, physical therapists, and myofunctional therapists all have expertise and a role to play in minimizing the symptoms of sleep-disordered breathing.
“Dealing with the way the bones, muscles, nerves and functions of the face and head operate may require the collaboration of several healthcare practitioners at times, but remember, small changes in starting conditions can have a huge impact on the outcome for your health and wellbeing.”
Tariq Kamal is a media consultant with Acumen Media.
Fantastic summary/perspective on the direction of orthodontics today. This underscores the need for
a team approach which will only be accomplished by concerned practitioners reaching out to each other.
Forming local networks for learning and referrals is key.
As the originator of the concept of Orthopostural Training, which regards the ‘teeth’ as the being the consequence of dysfunction in Posture, Breathing Behavior, Stress, Nutrition and Lifestyle, Dr. Raphael could not be more on target. It is essential that every health practitioner does whatever is required to get the patient out of trouble and pain free. However, the techniques – usually invasive – to attain that goal are usually not appropriate for long term management – but unfortunately are commonly used as such. There is too much literature available which highlights the negative consequences of long term PAP and Oral Appliance Therapy, for this to continue to be the “Gold Standard”. Where dysfunctional Anatomical and Behavioral patterns were to blame for the problem, more attention should be paid to reversing those issues. This is no longer a ‘dental’ ‘medical’ or other single speciality matter. The requirement is for a multi-modal approach, free from ‘ego’ to ensure the health of every patient.
Dr. R has done great job in clearly explaining the complex relationship between crooked teeth and susceptibility to non-communicable chronic illnesses like sleep apnea, attention deficit disorder….and possibly even type 2 diabetes, etc. Per his mention. “anthropological evidence points to rapid changes in dietary, early-life weaning and feeding, postural, and sleeping behaviors associated with modern styles as being significant progenitors to these determinant factors.”, this is the first time I have seen a practicing orthodontist actually acknowledge that the discipline of Anthropology can provide a scientific foundation for solving the relatively ‘recent’ problem of H. sapiens skeletal malocclusion…..nice work Barry!
Kev
WELL SAID BARRY! I have been “treating” adults with OSA with Oral Appliance Therapy for over a decade with a common theme running through the majority of them. Mouth breathing, poor tongue posture, chest vs diaphragm breathing, deficient maxillas, vaulted palates, retrognathic mandibles are common findings in these adults. I have been thinking over the years, “What would these adults be like if I could have helped them as a child? Would they still have Metabolic Syndrome and the other list of health problems plaguing their health histories?!” I personally think they would be completely different adults if someone would have taught them how to nose breathe, opened their airway, corrected the function and set them up with an amazing path for growth and development! There is NOT ONE SINGLE profession that is going to solve this epidemic in our western culture. This needs to be a MOVEMENT…a Team Approach of ENTs, Sleep Physicians, Pediatricians and Airway minded Dentists/Orthodontists that can identify these at risk kids and set them up to grow and develop to be their BEST SELVES! Thanks for writing this Barry and I’m so proud to be apart of this! Keep going AIRWAY WARRIOR!
Stacy
I am the director of orthodontics at LVI(a leading post graduate dental institute). This holistic approach to the disease of sleep disordered breathing, is right on!
Dysfunction of the tongue as relates to rest oral posture; breathing; and swallowing is perhaps the most underdiagnosed disorder in the profession of dentistry. Orthodontics is largely a mechanically driven treatment, that often overlooks key physiology. The greatest good we can do for our patients is to help them breath without compromises that hugely impact life in so many areas. If the structure of the face compliments the function of breathing/tongue, we have created health, beauty and minimized potential life long chaos. That should be our goal as clinicians. Straight teeth and damaged physiology need not be the norm.
Thank you, Barry, for helping to create awareness that
straight teeth and facial growth relate more to proper breathing than most people understand. As a Certified Orofacial Myologist, in practice for 40+years, I see the results of open mouth breathing: low tongue rest posture, forward head posture, poor speech and chewing patterns and orthodontic relapse. I agree with Roge that we must create a team where we find these issues early and treat them instead of waiting to try to correct them!
As a practicing pediatric dentist for over 43 years, this information represents the missing link for definitive orthodontic treatment and airway development . Although I was aware of the influence of breathing and its relationship to growth, I was still using traditional orthodontic procedures to expand and move the mandible forward. I was basically treating the symptoms not the cause of the problem. With airway and functional orthodontics, I can now provide treatment that not only creates a beautiful smile but also a healthy beautiful child
Barry is spot on in his summary.
I stand squarely in support of Barry’s comments and opinions.
As a profession we need to truthfully look inside our hearts and apply our minds to an integrative and multi-disciplinary “Medical Model” in preventing and/or treating Pediatric and/or Adult OSA.
The current model of treating OSA on a purely anatomical foundation, which primarily aims to enlarge the nasal and pharyngeal airways with only Orthopaedic/Orthodontic and/or Mandibular Advancement Appliances and/or surgery,is a highly flawed model.
OSA is a condition, which requires attention to Structure, Physiology and Psychology.
Breathing is a Behavior and until aspects of Breathing and Respiration associated with Dento-Facial and Cranial development are addressed using a multi-disciplinary Medical Model, treatment is doomed to be ineffective and/or subject to relapse.
It is my sincere wish that detractors, of a multi-disciplinary Medical Model of early recognition, evaluation, diagnosis and treatment of this very debilitating condition, are prepared to put aside prejudices and, in the name of good Science and in the best interests of the patients who put their trust in our knowledge and skills, open up to mutually respectful discussion and debate.
The relationship between sleep disordered breathing and the development of a child’s occlusion, facial growth and general health has been a eye opener. It is the missing link I have been looking for as a pediatric dentist practicing for over 40 years. Now we came produce beautiful smiles and beautiful faces along with general good health.
Thanks Barry for all your help and encouragement.
Well said! Its amazing how we are changing patients lives by integrating this type of treatment. Thank you, Barry!
Thank you Dr. Barry Raphael, excellent article! We know, “February is Children’s Dental Health Month.” There is a real need to shift our focus from just children’s teeth to also include children’s airway. How they chew, breath and swallow directly effects their orofacial and postural development. The interdisciplinary team approach to children’s health can ensure and safeguard future generations of healthy adults. The key is being able to recognize developmental airway problems early and address them.
Off course that we as orthodontist can help with airway and prevent sleep apnea.
I Ve been treating children for more than 20 years. And since 2012 I m working with five year old, helping to have a better airway
I agree with Dr. Raphael 100% that in some cases OSA can be prevented! It is all about PREVENTION and it starts with Medical & Dental Professionals identifying the signs and taking the appropriate course of action. Asking the patient about their sleeping habits and focusing on how they breathe is key! Sleep is more than the CPAP and appliances.
Thank you for sharing your knowledge Dr. Raphael!
I believe this specialty in orthodontics is extraordinary, while unfortunately representing very few in the field. Dr. Raphael understands how to integrate the wellness professions to best support families whose children demonstrate signs of future health limitations. What a valuable service to families who only knew orthodontics to be about appearances. They can now be more active participants in a bigger picture of health.
Barry, I am so proud of you for giving such a terrific and logical explanation of this facial development problem that is in an epidemic state in our children. Why allow patients to develop so poorly and produce such undesirable health consequences, like obstructive sleep apnea? This poor facial development is very preventable if seen by an astute dentist and who knows how to teach the parent what you profess. Keep up the great work. I am proud to stand with you. See you soon!
Dear Barry,
Please forgive my bad manners. I meant to open my comments on the 7th February 2017 by thanking you for your dedication and all the hard work you have put into spreading the word about an integrative and multi-disciplinary approach in treating OSA in children and adults and for attempting to unite the differing schools of thought from around the world.
It is my observation presently that change is occuring faster than we realise driven by the public who truly understand and want change.
In celebrating your achievement let us not forget the many unsung heroes before us who worked tirelessly and committed their lives and careers understanding and dealing with the “parts” but not being given the opportunity due to “pressure” groups to allow the greater profession and public to understand and make up their own minds.
Great summary and comments so far. Three points to be clarified : It is the volume of air per minute that is important when at rest. Generally speaking between 4 and 6 liters of air per minute for adults and about 8-12 1/2 liter breaths per minute with about 20 breaths per minute with infants who breathe far less per breath.
Also it is time to reference the issue properly as breathing disordered sleep. Sleep does not disorder breathing. Disordered or over breathing comes first most often with dominant mouth breathing. Finally an issue that must be considered as playing a part in all of this is the mistake the American Pediatric Association has made in recommending supine sleeping due to very poorly designed research well covered in the following article https://iahp.org/reassessment-sids-back-sleep-campaign-12232014/. Add to this the totally inordinate number of vaccines given to children all of which have a necessary inflammatory response leading to over breathing, colds, and worse which accelerate breathing end mouth breathing especially in the supine position.
Every time I hear Barry speak, or read something he has written, I’m impressed by his ability to take the complex and simplify it. This is a multifactorial problem and it requires an interdisciplinary team to help solve it. I hope that Barry’s message about PREVENTION as the goal will be heard loud and clear by pediatricians, dentists, ENTs and sleep docs.
I will often have a adult in my practice who is suffering from OSA who has classic signs of mouth breathing, poor oral rest posture, chest breathing and poor diet. And then, my next patient will be a young child with the same signs, whose parents already report issues with sleep and behavior, but are asking me about their teeth. The conversation always ends up talking about airway health and its influence on facial growth. Mom and Dad understand, but are often met with resistance from pediatricians and ENT when topics like tongue tie and large tonsils are discussed. I hope that Barry’s article becomes standard reading for physicians so they can understand how we can all work together for our patient’s health.
Keep up the good work, Barry!
Great stuff Barry as usual. Here are several additions: 1) Fast vs slower breathing is not a good data point.
I’m not sure how familiar clinicians are with what normal healthy breathing is for infants through to adulthood. While the healthy normal breathing for adults is 4-6 liters perminute at about 8 to 12 1/2 liter breaths perminute at rest, infants on through late adolescence vary quite a bit due to their needs and the norm for them is elusive. We do have a measure that can be used in Capnometry as well as a breath hold measure after exHale which is tricky and only well trained clinicians re this can assist in measuring it properly. . 2) sleeping does not in itself disorder breathing. Disordered breathing exists first which causes many disturbances in the physiology including accelerated flow of air over the critical opening in the airway causing inflammatory responses restricting the area and that is accelerated by mouth breathing greatly for many reasons in addition to the excess volume and condition of the air. Therefore we should rightfully call it breathing disordered Sleep or even breathing and positional disordered Sleep as the position of sleep can accelerate or slightly alter the rate of over breathing. An issue that needs to be addressed as week in regard to this is the poorly researched notion promulgated by the American Pediatric association that supine sleep is the preferred position. Not only does that cause further disordering of poor breathing, it significantly delays the development of the muscles that lift the head which has consequences in terms of many things going forward including facial development and breathing. Prone sleeping should instead be the norm. I’ll post a well documented research piece about this latter shortly.
Finally though it may tread on sacred ground, vaccinations have an enormous inflammatory effect on children often causing cold or flu like symptoms which accelerate mouth breathing . Authoritative spokespersons of great respect, like Robert Kennedy Jr. , are pilloried and banned from appearing in any national popular media despite their clear factual presentations that give the corrupt history of vaccinations and the CDC and pharmaceutical companies who spend double the amount of money lobbying congress than any other business including big oil.
Here is the article challenging the health of supine vs prone sleep https://iahp.org/reassessment-sids-back-sleep-campaign-12232014/
Thank you Barry for concisely describing how and why orthodontics is about so much more than just straight teeth.