Thank you, Dr. Montrose! We so appreciate the overview on OMT for sleep apnea. As a kid, me and my siblings went through OMT just before getting our braces. I honestly can’t recall any benefit (other than the soda (!) we received during therapy for evaluating our swallow position – a big deal in our household). As an adult however, I occasionally experience apnea and am happy to revisit OMT as my solution! ~DrKF
Obstructive Sleep Apnea: Using Orofacial Myofunctional Therapy as a Part of a FxMed Approach to Treatment
Obstructive Sleep Apnea is a condition affecting up to 22 million Americans and close to 1 billion people worldwide.
This condition can have serious impacts on overall health and has been shown to be a contributing factor to:
- heart disease
- diabetes
- stroke
- cognitive decline
- weight gain
- daytime fatigue
- anxiety
- depression
- chronic pain
- teeth grinding
- and chronic headaches
There are a variety of treatment options available to manage Obstructive Sleep Apnea including Positive Airway Pressure devices (the most common being CPAP), dental mandibular advancement appliances, and various surgeries, but there are also functional treatment approaches that can target the underlying causes of the disease.
What we know is that Obstructive Sleep Apnea occurs when a person’s upper airway, directly behind the mouth, collapses during sleep restricting or blocking airflow to the body. This can happen due to a structural problem if the size of the airway is too small, a functional problem if the tissues surrounding the airway are loose, or both.
All of the treatment options for Obstructive Sleep Apnea have the same goal, which is to prevent this collapse from happening in order to maintain steady airflow to the body during sleep. While Positive Airway Pressure devices and dental mandibular advancement appliances are beneficial to many people there is an additional component that is often not addressed, and that is the functional ability of a person to increase the size and reduce the collapsibility of their own airway.
What research has shown is that in addition to reducing snoring, jaw and facial pain, Orofacial Myofunctional Therapy can reduce Obstructive Sleep Apnea by up to 50% in adults and 62% in children. Orofacial Myofunctional Therapy is the neuromuscular and functional reeducation, strengthening, and toning of the muscles of the mouth, throat, and face. Most people in our modern society have some form of Orofacial Myofunctional Dysfunction which can start as early as infancy or develop later in life.
Where does Orofacial Myofunctional dysfunction come from?
Believe it or not the first factor that can lead to the development of dysfunction can be diagnosed immediately after birth.
Tongue and lip ties are restrictive tissues attached to the tongue and lips that can limit the amount of movement possible. These restrictive tissues were meant to dissolve before the infant was born but sometimes the tissues remain to a degree that can prohibit proper function.
Historically these tissues were cut at birth by the midwife, but in modern society this is not always done. If the lip and tongue remain functionally restricted then this can lead to difficulties with feeding that can include pain for the mother, inefficient feeding for the child, increased swallowing of air, failure to thrive, or complete inability for the child to breastfeed. Additionally, it creates a different swallow pattern where the child will use facial muscles to aid in swallowing to compensate for the lack of tongue mobility. A tied tongue also tends to sit low against the lower jaw rather than up against the upper jaw and roof of the mouth as it should.
As a child’s facial bones are growing and developing this altered tongue resting position and swallow pattern, where the muscles of the lips and cheeks contract to push in on the facial and jaw bones rather than the tongue resting on the roof of the mouth and pushing up and out during swallowing, will change the forces on the facial bones and has been shown to lead to a narrower, longer face with a smaller mouth and increased dental tooth crowding later in life. If the bones of the jaws do not grow fully due to this change in function, the space inside the mouth is smaller leaving less room for the tongue, and since the tongue grows independently from the facial bones it may look like the tongue is too big for the mouth but in most cases it is the mouth, that due to dysfunction, did not grow large enough to accommodate the tongue. Now there is a structural problem, and if the tongue does not fit in the mouth as it should, it will be forced backward into the airway directly behind the mouth and can cause a restriction which can increase air turbulence and lead to snoring or sleep apnea. It is amazing how such a small piece of tissue can have such a huge impact.
The other dysfunction that can be addressed early in life is mouth breathing. When a growing child breathes through their mouth their tongue is forced down which leads to all the same problems as a tongue tie including long, narrow faces and dental crowding. Additionally, when mouth breathing, the inhaled air bypasses the nose which is built to warm, filter, and humidify air before it reaches the sensitive tissues of the throat and lungs. When cold, dry, and dirty air bypasses the nose and goes directly through the mouth to the throat and lungs there is increased risk of inflammation of the adenoids and tonsils, increased nasal congestion, and increased risk of irritating the tissues of the lungs and contributing to asthma.
The Spectrum of Sleep Disordered Breathing
Mouth Breathing during sleep is also the first step on the spectrum of Sleep Disordered Breathing, with the last step being Obstructive Sleep Apnea, and has been shown to impact a child’s health and behavior in a variety of ways including increased symptoms of ADD/ADHD, increased anxiety and depression, decreased IQ, bedwetting, teeth grinding, restless sleep, nightmares, delayed growth, daytime fatigue, and crowded teeth later in life.
Once these dysfunctions have started, without treatment it is very rare for them to reverse on their own, and many times they continue to progress leading to a cascade of symptoms throughout life. Ideally, Orofacial Myofunctional Dysfunctions, tongue and lip ties would be evaluated and treated at birth, but this can be done at any age. The longer the condition and resulting dysfunction exists the more compensations the body will make, and this can add additional components to proper treatment.
For an infant, breastfeeding and nasal breathing will act as Orofacial Myofunctional Therapy and as long as there are no restrictive tissues in the tongue or lips then growth should progress normally and a normal airway and mouth will develop.
Functional Therapies and Long Term Benefits
Later in life, if a tongue or lip tie is discovered it can still be treated but will need to be accompanied by therapy to correct the dysfunctional habits that developed to compensate for the restricted tissues. If the condition lasts beyond the years of facial growth then comprehensive treatment will likely involve promoting further development of the jaw bones towards the development that would have occurred naturally if unrested tissues and proper function were present. Luckily there are treatments available today that can promote such development at any age, and along with functional therapy can correct the underlying causes of many of the symptoms so common in modern society.
While functional therapy can be beneficial on its own, it also has been shown to increase the compliance and effectiveness of Positive Airway Pressure devices and dental mandibular advancement appliances. It is important to understand that Obstructive Sleep Apnea is a multifactorial disease and therefore the best treatment will often involve a combination of therapies.
By including a functional component to the evaluation and treatment of patients it is possible to manage, prevent, and even cure Obstructive Sleep Apnea. The best medicine is always prevention so an early evaluation of children can often catch early signs of dysfunction and correct the problems that lead to Obstructive Sleep Apnea from developing in the first place. For an older child or adult being aware of, and evaluated for, signs of Orofacial Myofunctional Dysfunction in addition to any structural deficiencies will allow for the most comprehensive treatment approach and highest level of success.
References:
https://www.drmichaelgelb.com/
https://academic.oup.com/sleep/article/38/5/669/2416863
https://www.mdpi.com/2076-3271/5/4/30/htm
https://academic.oup.com/sleep/article/27/6/1131/2696740
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6132228/
https://pubmed.ncbi.nlm.nih.gov/21032979/
https://www.liebertpub.com/doi/abs/10.1089/bfm.2011.0030
https://link.springer.com/article/10.1007/s11325-019-01929-w
By Dr. Jeremy Montrose
