What would you do if you saw a beefy uvula in one of your patients? What if someone’s tongue looked bigger than their mouth? What would you write in your chart notes about asymptomatic large tonsils in a 40-year-old person? In my experience, I think, “Huh, that’s weird,” and then go on my merry way to perio chart or do something treatment related.
I’m not sure that I’ve ever seen chart notes that mention any of these, so I’m betting few people write down these observations.
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What is a true oral-systemic practice?
Some people think an oral-systemic practice means identifying periodontal disease and sending the patient to the cardiologist with a periodontal chart and a few research papers. But it’s more than that. While periodontal disease is inflammatory, it’s not as inflammatory as sleep apnea.1,2
There are some new anatomical terms that can help you communicate to patients and their primary practitioners the true systemic consequences of oral conditions. Patients deserve a hygienist who is informed about how oral conditions manifest systemically. Here are some expressions of systemic diseases that look like oral problems.
You might also be interested in: How mouth taping can be key to achieving healthy nasal breathing
Diabetes/periodontal disease: First is the big one that’s obvious and not-so-obvious at the same time. If a patient has bleeding on probing (BOP), they may be metabolically compromised. Metabolic syndrome affects the microvasculature of the sulcus well before the perio pathogens show up.
Once metabolic syndrome advances, the microvasculature becomes flimsy and allows things to pass by the membranes and the walls of the capillaries. Think about leaky capillaries. Any little bump in the action can cause bleeding.
Nocturnal enuresis (NE), aka bed-wetting: This is tied to sleep-disordered breathing (SDB) in children. An insufficient airway in a child causes trouble with the antidiuretic hormone and many hormones become unbalanced. Up to 10% of 12-year-olds suffer with nocturnal enuresis. It’s impossible to see an evolutionary benefit to NE.3,4
Sinus problems: The palate is the floor of the maxillary sinus. If that doesn’t grow wide, it ends up resembling a mountain inside the sinuses, causing the septum to kink. If an adult patient presents with an idiopathic deviated septum, check why the palate wasn’t stimulated to grow; it’s likely a tethered tongue. If arch development is approached as early as 18 months of age, this may be prevented.
Gastrointestinal problems: Poor nutrition is common in people who have a restriction in tongue mobility. It’s hard to chew when the tongue is trapped. The term “posterior tie” has become popular. A posterior tie is a restriction of mobility of the middle or posterior third of the tongue. This may or may not be in conjunction with a classic anterior ankyloglossia. When focusing on tongue extension, many of the posterior restrictions that interfere with the oral and pharyngeal phase of a swallow are undiscovered. People with this tie often chew very little and swallow large pieces of food into the stomach. Studies show this kind of restriction can cause GI distress.
Maxillary torus: A neurological circuit is completed when the tongue is in position against the palate. If the circuit is open, the hypothesis is that the palate will reach down in an effort to close that circuit.5 This open circuit can increase the parasympathetic system (for example, heartbeats and respiratory rhythm decrease).
But if the tongue is positioned against the soft palate, the sympathetic system will reduce its activity. A large maxillary torus takes up tongue room, potentially forcing the tongue back into the oropharyngeal airway. Current studies investigating this complication are lacking, although there is one paper on the mandibular tori taking up tongue space6 and contributing to sleep disordered breathing and other problems, such as high blood pressure, erectile dysfunction,7 and stroke.8
Mandibular tori: The floor of the mouth attachment of the tongue should be in the middle of the floor of the mouth at the level of the premolars. If it’s attached to the mandible, bone may be laid down to relax the tension.9
Diabetes type 3: This metabolic condition has gone undiagnosed and undertreated for decades. Noticing things such as bleeding gums and recommending a blood panel could make a huge difference in someone’s life decades before their brain becomes irreversibly damaged from glucose resistance.
- High blood pressure: Oral breathing upsets the delicate balance between at least two blood gases. Too much CO2 is expelled during oral breathing. While we look at CO2 as a greenhouse gas, the body uses it to relax smooth muscle, which surrounds the cardiovascular system. Smooth muscle makes up nearly the entire GI system.
- Bloating and gas: Low tongue posture and possibly hyperventilating can cause problems with the lower GI tract.10 As mentioned, overbreathing can remove too much CO2 from the body and affect the motility of the intestines.
- TMJD: Open-mouth breathing places stress and strain on the small muscles and supporting structures of the jaw joint.
- Cardiovascular disease: With oral-systemic revelations, hygienists have been educating other health-care professionals and patients that oral bacteria can cause heart and cardiovascular disease. Flossing or using a water flossing device is good practice, but until the systemic inflammation is curtailed, nothing will stop the gum tissue from becoming inflamed. But why is the body inflamed? Could it be snoring or sleep apnea? A recent meta-analysis of 16 papers representing more than 10,000 patients concluded that snoring increases risk of cardiovascular disease by 46%.11
- Snoring: In children, snoring is often confused with ADHD.12,13 Dementia is more common in those who snore or have sleep apnea.14
Learn a new oral-systemic vocabulary
What can you do about these problems? You can start by learning the following terms and using them when assessing patients.
Craniofacial respiratory complex: Use this term anytime you refer to the face.
Airway: Use this term instead of throat.
Ventral funnel: This is the pull of the frenum on the underside of the tongue, causing a ventral-shaped pull of the muscle during lingual palatal suction. This is an indication of a posterior tie.
Lingual palatal suction: This is a posture of the tongue in full occlusion against the palate to assess a posterior tongue-tie.
Three occlusions: This is tongue to palate, lips together, teeth mostly together.
Primate spacing: This means no appreciable spacing between the primary teeth in children entering the mixed dentition stage. Lack of primate spacing can lead to increased risk for dental decay.15
Early childhood malocclusion (ECM): ECM may be caused directly by a tongue-tie, which could have been detected in infancy. Allergies that keep the mouth open for breathing can interfere with proper development of the maxilla and impede arch development, contributing to ECM.16
Blade of the tongue: This is the distance between the insertion of the frenum into the tongue and the tongue tip. If it’s less than 16 mm at any age, look for other evidence of a tongue-tie, such as poor arch development or high blood pressure.17
Crowded teeth: By age five, the primary teeth should have enough room between them to insert a nickel. Dental crowding may be the first indicator of a health condition. Examples range from simple malocclusion16 to nocturnal enuresis, ADHD, and sleep apnea.18
Ectopic frenum attachment: This is when the frenum is attached to the mandible rather than the floor of the mouth.
Enlarged or elongated uvula: This indicates snoring. If the health history or the blood pressure screening reveals elevated blood pressure, this could be added to the differential diagnosis of sleep-disordered breathing (SDB).19
Sleep-disordered breathing: This is snoring, obstructive sleep apnea, hyperventilation, and oral breathing. SDB can lead to high blood pressure, dental decay, periodontal disease, dementia, or stroke.19
Vaulted palate: This may be caused from a lack of pressure from the tongue and cheeks in utero or later.
Idiopathic deviated nasal septum: This may be caused by a lack of pressure from the tongue against the palate during infancy. The brain causes the top of the head to grow, but there’s a lack of growth of the midface, causing this bend in the septum.
Mallampati or Friedman score: This is a visual score of the amount of the oropharynx visible with the tongue out (Mallampati) or in (Friedman).
Ask questions and collaborate
It’s time to start talking to your patients about the information I’ve presented here. Ask, “Did anyone ever tell you your uvula is really long?” Ask them if they snore. Once you become comfortable with a conversation, incorporate some other new things, such as saliva testing for pathogens. Find out how to track your findings in patients’ electronic health records and print reports to share with your team at meetings.
Most dental practices have working relationships with periodontists, orthodontists, pediatric dentists, and endodontists, and some even with cardiologists. But what about a lactation specialist, a nutritionist, a chiropractor, or an orofacial myofunctional therapist? Start building a team of specialists and make a difference in your patients’ lives now.
Editor's note: This article appeared in the August 2023 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
- Gaines J, Vgontzas AN, Fernandez-Mendoza J, He F, Calhoun SL, Liao D, Bixler EO. Increased inflammation from childhood to adolescence predicts sleep apnea in boys: a preliminary study. Brain Behav Immun. 2017;(8)64:259-265. doi:10.1016/j.bbi.2017.04.011
- Orrù G, Storari M, Scano A, Piras V, Taibi R, Viscuso D. Obstructive sleep apnea, oxidative stress, inflammation and endothelial dysfunction: an overview of predictive laboratory biomarkers. Eur Rev Med Pharmacol Sci. 2020;(6)24:6939-6948. doi:10.26355/eurrev_202006_21685
- Wada H, Kimura M, Tajima T, et al. Nocturnal enuresis and sleep disordered breathing in primary school children: potential implications. Pediatr Pulmonol. 2018;53(11):1541-1548. doi:10.1002/ppul.24156
- Zaffanello M, Piacentini G, Lippi G, Fanos V, Gasperi E, Nosetti L. Obstructive sleep-disordered breathing, enuresis, and combined disorders in children: chance or related association? Swiss Med Weekly. 2017;147:w14400. 10.4414/smw.2017.14400
- Bordoni B, Morabito B, Mitrano R, Simonelli M, Toccafondi A. The anatomical relationships of the tongue with the body system. Cureus, 2018;10(12):e3695. doi:10.7759/cureus.3695
- Ahn SH, Ha JG, Kim JW, Lee YW, Yoon JH, Kim CH, Cho HJ. Torus mandibularis affects the severity and position-dependent sleep apnoea in non-obese patients. Clin Otolaryn. 2019;44(3):279-285. doi:10.1111/coa.13286
- Bozorgmehri S, Fink HA, Parimi N, et al. Study: Association of sleep disordered breathing with erectile dysfunction in community-dwelling older men. J Urol.2017;197:776-782. doi:10.1016/j.juro.2016.09.089
- Titova OE, Yuaz S, Baron JA, Lindberg E, Michaëlsson K, Larsson SC. Sleep-disordered breathing-related symptoms and risk of stroke: cohort study and Mendelian randomization analysis. J Neurol.2022;269(5):2460-2468. doi:10.1007/s00415-021-10824-
- Valentin R, Julie L, Narcisse Z, Charline G, Vivien M, David G. Early recurrence of mandibular torus following surgical resection: a case report. Int J Surg Case Rep. surgery case reports. 2021;83:105942. doi.10.1016/j.ijscr.2021.105942
- Hill RR, Pados BF. Gastrointestinal symptom improvement for infants following tongue-tie correction. Clin Ped. 2023;62(2):136-142. doi:10.1177/00099228221117459
- Vgontzas AN, Liao D, Pejovic S, et al. Insomnia with short sleep duration and mortality: the Penn State cohort. Sleep. 2010;33(9):1159-1164.
- Lee SY, Guilleminault C, Chiu HY, Sullivan SS. Mouth breathing, "nasal disuse," and pediatric sleep-disordered breathing. Sleep Breath. 2015;19(4):1257- doi:10.1007/s11325-015-1154-6
- Prajsuchanai T, Tanphaichitr A, Hosiri T, Ungkanont K, Banhiran W, Vathanophas V, Gozal Prevalence of high-risk for obstructive sleep apnea in attention deficit hyperactivity disorder children referred to psychiatry clinic and impact on quality of life. Front Psych. 2022;13:926153. doi:10.3389/fpsyt.2022.926153
- Guay-Gagnon M, Vat S, Forget MF, Tremblay-Gravel M, Ducharme S, Nguyen QD, Desmarais P. Sleep apnea and the risk of dementia: a systematic review and meta-analysis. J Sleep Res. 2022;31(5):e13589. doi:10.1111/jsr.13589
- Cho VY, King NM, Anthonappa RP. Correlating spacing in the primary dentition and caries experience in preschool children. Eur Arch Paediatr Dent. 2021;22(3):393-397. doi:10.1007/s40368-020-00566-2
- Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ital. 2016;36(5):386-394. doi:10.14639/0392-100X-770
- Kotlow L. Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1064 diode lasers. Eur Arch Paediatr Dent. 2011;12(2):106-112. doi:10.1007/BF03262789
- Aroucha Lyra MC, Aguiar D, Paiva M, Arnaud M, Filho AA, Rosenblatt A, Thérèse Innes NP, Heimer MV. Prevalence of sleep-disordered breathing and associations with malocclusion in children. J Clin Sleep Med. 2020;16(7):1007-1012. doi:10.5664/jcsm.8370
- Chang ET, Baik G, Torre C, Brietzke SE, Camacho M. The relationship of the uvula with snoring and obstructive sleep apnea: a systematic review. Sleep Breath.2018;22(4):955-961. doi:10.1007/s11325-018-1651-5