BY Shirley Gutkowski, RDH, BSDH
Being called a mouth breather used to be a derogatory term used to describe someone who was, well, here's the Urban Dictionary definition:
1. Literally, someone who lacks enough intelligence that they never learned to breathe through their nose.
2. A really dumb person.
Maybe that's why we don't talk about mouth breathers much in dental hygiene. We don't want to use derogatory terms for our patients, and for the most part it seems as if the only outcome of not breathing through your nose is dried-out gingival tissue and perhaps some erythematous color changes in the tissue of the upper anterior gingivae. No biggie, or maybe it is a big biggie. Mouth breathing decreases the pH of the entire body.
Physiologically the type of air, the quantity of air, and what the body does with it is very complex. For a great explanation, you can tune in to Lectures in Respiratory Physiology by UCSD Professor John B. West, MD, PhD, on YouTube. When breathing takes place through the mouth, a great deal of physiology cannot take place, moisturized air comes from the sinuses, and that's the big issue missing in mouth breathers. Mouth breathing affects the pH of the entire body, meaning the blood ... meaning the saliva.
Other articles by Gutkowski
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- The Autism Experience: Helping practice families deal with autism
- The myth of cross-training
A low pH oral environment is not only corrosive to the teeth directly, but the acidic pH activates the acidophilic and acidogenic bacteria to set up housekeeping. Building a healthy biofilm in the presence of acidic saliva is nearly impossible. Acid begets acid.
So why do people breathe through their mouths? Most certainly there's a component of sinusitis; mouth breathing as a defense to get air before something more drastic occurs, such as surgery. Another easy-to-determine factor that causes a person to breathe through the mouth is lip patency. If the lips don't close, people breathe through their mouths. Anterior or posterior tongue-tie, or placement habits of the tongue can interfere with lip patency, which contributes to mouth breathing. If tongue placement is the cause, a trained orofacial myofunctional therapist may be able to help.
Then there are external stimuli that cause enlarged tonsils and adenoids, which obstruct the nasal breathing system. Food allergies as well as environmental allergies contribute to enlargements in those two major air-filtering organs. Correcting open mouth breathing may contribute to a physiological shift of systemic acidosis.
Mouth breathing is a condition or symptom that affects the oral environment; therefore, there's a high need to disregard definitions such as the ones above and focus more on the classic dictionary definition of mouth breather from Merriam-Webster's online dictionary:
Mouth breather: one who habitually inhales and exhales through the mouth rather than through the nose
Mouth breathers and people who are enjoying a diet that promotes systemic acidity both want something easy to keep them healthy. It's not easy to get people to change up their diet to save their teeth. Weston Price, a dentist from the first half of the 1900s (remember the 1900s?), found that indigenous people did not have dental decay until the "superior" Western diet found its way to them. Only then did they suffer Western diseases, most obviously obesity and dental decay. Why would they take up a diet that makes them sick? It tastes good. As much as everyone complains about Twinkies and bourbon, they are yummy.
If we can't get our patients to eat differently, it doesn't mean we can shrug our shoulders and call it a day. We have a professional responsibility to our patients, and blaming them for their disease is not fair to them or our enormous student loans or almost 3,000 hours of education in how to help people keep their teeth. It seems customary to couch the blame in the phrase: They must own their own disease.
What we can do is provide simple and effective habit substitutes. We know that breaking a habit is nearly impossible and starting a new habit is just as hard. And like it or not, one habit will be replaced by another, so finding an alternate habit is a good strategy. Uninspired replacement can't work, such as offering a bottle of water in place of a fizzy, delicious, sweet, and caffeinated beverage.
Foods high in arginine fit into nearly all diets. There aren't too many people who are going to be OK eating sea lion liver - the food highest in arginine - and the same goes for defatted peanut flour. But spinach is pretty arginine dense and even fits on a ketogenic diet, aka Atkins. Ask Google for other foods high in this amino acid. Xylitol is also a great adjunct for modifying the oral environment by offering a neutral effect on any diet. Arginine and xylitol affect the bacteria, but what about the teeth directly?
Xylitol is effective at reversing enamel damage although the science hasn't evolved much past one or two studies. There are also highly effective, rigorously studied pastes on the market that provide teeth with the full mineral profile necessary to rebuild enamel. The low pH environment - created by mouth breathing or the diet - is exactly the environment in mind of the researchers who developed the Recaldent paste known in the United States as MI Paste. The paste wasn't built to remineralize teeth in a vacuum; it was developed to work with saliva.
In a person with poor quality saliva, low pH, or low buffering, the Recaldent molecules in MI Paste work quickly. A few times a day the patient will apply the paste to their mouth where the molecules stick to hard and soft tissues and the cell walls of bacteria. As the day wears on, the Recaldent molecules are stripped of their coating during an acidic challenge and release the amorphous calcium and phosphate into the environment. Imagine the reaction in the bacteria when the squirt of acid just produced creates a buffering condition nearly immediately. At the very least that germ will be very uncomfortable.
The calcium and phosphate molecules have an affinity for the damaged enamel. To top it off, that tiny chemical reaction dives into the enamel under the pseudo intact enamel and fills in from the bottom. Fluoride on its own won't do that. Fluoride will seal over the top, fortifying that pseudo intact enamel, and in so doing will block the attempts of calcium and phosphate to penetrate in the future. Check the teeth of the kids who had brackets removed two years ago and had fluoride varnish applied right away. They still have the white check boxes on their teeth.
Mouth breathing has a more acute effect on teeth too. Dry teeth and tissues are at high risk for decay and periodontal disease. People with conditions or medications that cause dry mouth are in that same category. Their teeth need protection. Compliance with trays is pretty low, specifically when the trays are for fluoride. A tray as a medical device is used for applying deep medication to pockets or a basic fluoride tray may be a carrier for the Recaldent paste in people with dry mouth and pockets. Even applied topically without a tray, the paste will heal the damaged enamel and even repair microscopic damage to the cementum plus alter the environment to fortify health biofilm.
Those with dry mouth, such as people with Sjögren's, can benefit more from applying the Recaldent paste to the soft tissues as well as the teeth. The soothing cream is really like no other in its ability to coat the tissues and relieve dry mouth so that sleeping through the night is once again a reality.
Looks like we covered a lot of ground! From mouth breathing, to Twinkies, to Recaldent, oral health-care providers can offer so much more to their patients with pH fluctuations of the oral cavity. The products are here! They were created for us to have an answer for our patients' problems ... to break the acid begets acid cycle. Let's dust off a few synapses and start looking like heroes.RDH
Other saliva quality disruptors
Saliva quality may also be affected by diet. There are so many ways people eat today that it's nearly impossible to address every diet or dietary leaning. Patients could be sent home with litmus paper and test their saliva 15 minutes after each meal for a week to get a good feel for the effects their food choices are having on their saliva. To test, the patient should collect pooled saliva into a teaspoon and use the test paper in that collected saliva as opposed to testing in their mouth where contaminants and variables are many.
While the diagnostic exercise may be necessary to determine salivary pH, to root out the problem requires a lot more investigation. There are things a clinical oral health-care provider can do to protect the oral tissues; for instance, protecting the teeth with fluoride varnish and making pinpoint dietary changes.
Fluoride varnish may be part of a total treatment plan that includes referrals to specialists who deal in the underlying causes for low oral pH. An appropriate fluoride varnish will make the teeth more resistant to the acids for a short time. By definition, acidic saliva has less calcium than neutral, so providing that mineral to the teeth is necessary. A fluoride varnish that contains calcium and phosphate would be preferable. A varnish that contains CPP-ACP, known as Recaldent (available from GC America), found in MI Varnish (GC America), would be even better as the chemistry is already worked out to make sure the amorphous calcium is available to the tooth and the fluoride is creating a surface that is most resistant to the acidic environment.
Imagine how this works. The thin coat of fluoride varnish is applied and the Recaldent molecules become exposed to the oral environment. As the environmental pH fluctuates, the ACP is released as the CPP coating is removed during an acid challenge. A little chemical reaction is created where the fluoride, calcium, and phosphate build up microscopically damaged enamel at the base of the lesion, not just on top where traditional fluoride varnishes work.
Shirley Gutkowski, RDH, BSDH, is the author and publisher of The Purple Guide series of books for dental hygienists. She is also the host of the popular daily radio podcast on Blog Talk Radio and Stitcher: Cross Link Radio. Gutkowski is a faculty coach at CAREERfusion. She can be reached for speaking or consulting at [email protected].