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BackTable / ENT / Article
Chronic Mouth Breathing: Clinical Evaluation & Treatment
Megan Saltsgaver • Updated Oct 23, 2024 • 33 hits
Chronic mouth breathing can lead to various health issues, including headaches, poor sleep, and jaw tension, often exacerbated by conditions such as teeth grinding and sleep apnea. During a physical exam, specific red flags can alert providers to the presence of chronic mouth breathing and its accompanying issues. While it's never too late to address these issues, treatment options can vary depending on the patient’s age. General otolaryngologist Dr. Colleen Plein explains the connections between mouth breathing, sleep apnea, and related symptoms, highlighting the importance of comprehensive evaluation and treatment to promote better respiratory health and overall well-being.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Chronic mouth breathing manifests as headaches, poor sleep, jaw tension, and poor posture. Physicians should always have high suspicion of chronic mouth breathing in otherwise healthy patients presenting with these symptoms.
• When examining these patients, it is important to look in their nose without decongesting them. Nasal endoscopy, a small camera, will often be used very first when evaluating the patient. During the oral exam, key indicators such as scalloped edges on the tongue, high-arched palates, enlarged tonsils, and jaw alignment can provide insights into potential sleep-disordered breathing and mouth breathing habits, guiding further evaluation and treatment.
• Teeth grinding can often be one of the consequences of chronic mouth breathing due to tense jaw muscles from being open all the time, thus causing clenching or grinding when finally closed.
• Sleep apnea is another issue that chronic mouth breathers often present with. Sleep studies should be considered in chronic mouth breathing patients.
• Treatments for chronic mouth breathing range from behavioral retraining to more invasive options such as surgery. There are other helpful options such as the trendy mouth taping, Breathe Right strips, and oral appliances to help with sleep apnea and teeth clenching.
Table of Contents
(1) Physical Examination of Chronic Mouth Breathing
(2) Mouth Breathing, Teeth Grinding & Sleep Apnea
(3) Chronic Mouth Breathing Treatment
Physical Examination of Chronic Mouth Breathing
When evaluating a patient suspected of being a chronic mouth breather, Dr. Plein emphasizes the importance of assessing the nose in its natural state, without using decongestants. Decongesting the nasal passages can make the nose appear normal and hide underlying issues.
The initial step typically involves a nasal endoscopy and examining the patient’s facial structure to identify signs of underdevelopment, such as a high-arched palate caused by an underdeveloped maxilla, which can lead to nasal septum collapse.
A thorough examination of the nasal valve, both internally and externally, helps determine if the nasal passages remain open. A CT scan can also be valuable for identifying bone spurs on the posterior nasal septum, as well as conditions like concha bullosa (air-filled turbinates that block airflow) and potential sinus disease.
[Dr. Gopi Shah]
As far as your evaluation, when you're evaluating the nose, anything particular or special or different because you are more focused on not just being able to breathe, but truly good functional nasal breathing, meaning when you look with a scope, are you looking before Afrin, after Afrin? Are you doing modified caudal? When you use a speculum, that's spreading the nose open. That changes how it looks. What are ways that you've modified your exam as you've started to hone in on nasal breathing?
[Dr. Colleen Plein]
I never decongest anybody before I examine them because who walks around decongested? No, seriously.
[Dr. Gopi Shah]
No, that's a good point.
[Dr. Colleen Plein]
If you decongest anybody, their nose is going to look perfect. For me, decongestion is like if you're going to do a flexible scope on somebody and just want to make it less uncomfortable, but even then-- I don't decongest anybody. Everybody gets a nasal endoscopy. I pretty much never even pull out the speculum because you want to see the nose in its most normal state. Looking at, again, their facial anatomy. Is their maxilla narrow? Is their face long? Looking at their nasal valve is super important, both externally and internally.
A caudal maneuver is going to help almost anybody breathe better, but looking for a static and dynamic collapse. That's why the scope is helpful too, because you'll stick a scope in and they'll have this horrible valve and then everything behind it is fine. The other thing that's really important for me that I have found, which I think is contrary to our thinking, is I really want to have a scope exam and a CT scan of the sinuses because I cannot tell you how many times the CT is just so revealing, especially-- We don't really do a great job of examining the posterior septum.
You'll see these people who you think, "Oh, their septum is not so bad," and then they get a scan and they have these horrible posterior spurs, just like ridiculous noses. Conversely, you'll get a scan and you'll look at the scan and you'll be like, "You know what? Their airway doesn't look so bad. It looks pretty open." You'll stick a scope in there and there's no room, none whatsoever. They're very complementary to each other. Again, also you're looking for things like concha bullosa, obviously sinus disease if there is any. You can actually appreciate the nasal valve pretty well on a CT scan on the most anterior coronal cuts.
You can actually see the concavity that happens there and really appreciate how much it obstructs the anterior nose. I do like to get a CT on almost everybody before deciding what I'm going to do with them.
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Mouth Breathing, Teeth Grinding & Sleep Apnea
Teeth grinding (bruxism) in children can often signal underlying issues related to sleep-disordered breathing, including sleep apnea. Dr. Plein notes that while some kids may grind their teeth between the ages of three and six without cause for concern, it’s essential to investigate further if other symptoms are present, such as snoring or chronic mouth breathing. Bruxism may stem from the body instinctively trying to reposition the jaw to improve airflow during sleep, a phenomenon linked to upper airway resistance syndrome.
Children with dental issues, like a high-arched palate, may struggle with proper tongue positioning, leading to a tongue thrust, which can create scalloped edges on the tongue—a sign of obstructive sleep apnea. This tongue behavior indicates that there is insufficient space for the tongue to rest comfortably, pushing against the teeth instead. Such structural problems can exacerbate sleep apnea, as mouth breathing generates higher airflow pressure that increases the likelihood of airway collapse during sleep.
This interplay between teeth grinding, sleep apnea, and mouth breathing underscores the need for thorough evaluation and potential interventions, such as myofunctional therapy, to address the root causes and improve overall respiratory health.
[Dr. Gopi Shah]
In terms of teeth grinding in kids, I find, especially between the ages of three to six, is that some kids just do that and then it gets better, or is that something that we think of as related to sleep-disordered breathing in the young pediatric patient? I don't know how to place teeth grinding in the kid that comes in that-- Again, maybe it's just my narrow, "Are you snoring? Are you mouth breathing? Do you have pauses, poor concentration, bedwetting, attention?" Yet it may not be much of any of those things, but there may be teeth grinding and maybe an attention concern.
I might see two plus tonsils, but I'm like, "Do I watch you? Do I get a sleep study? Does this mean anything?" I don't know where to put that.
[Dr. Colleen Plein]
Yes. Again, caveat, I'm not an expert in peds. I would say that it's at least worth investigating. I feel like this is where we get in-- especially in kids. In kids, an AHI over one is sleep apnea. It's at least worth investigating. In that case, I would, "Do they have allergies?" A trial of Flonase is not going to hurt. The sleep studies I understand, in kids are a little more difficult. Also, we got to think about this thing is, we're not just dealing with sleep apnea.
It's just this upper airway resistance syndrome-type thing. Again, do you see those other signs. Do do you see the high arched palate? It's the parents. Are they breathing-- That might someone, if they can tolerate it, might be a good candidate for something like myofunctional therapy. Maybe it's just more of a habitual thing. Maybe it's a little bit of a dietary change. Maybe they just need some nasal sprays or their allergies addressed. Whatever you can do to get them breathing better.
Again, I don't think there's necessarily hard data to support this, but the thought is that the bruxism is your body automatically trying to give you a jaw thrust to help you breathe better. That's where it's coming from. it's what they call parafunctional activity that's stemming from improper breathing. I'm sure you tell parents, a kid that snores, it's never normal to have a young kid that snores. It's probably not that normal to have a kid-- they're in your office for a reason. Someone sent them there for some sort of problem. There's something going on.
[Dr. Gopi Shah]
You're right. It's usually the dentist, to be honest with you, which is great because there is some communication and collaboration, but sometimes because, like you said, I think from the beginning in our ENT, our traditional literature, whatever, or what we learn, and maybe the education is changing now, but teeth grinding and sleep apnea in kids, it's not one of your classic or even in the constellation. I see a lot of teeth grinding, but as well as tongue thrust. I don't always know where to place that and what that means.
[Dr. Colleen Plein]
The tongue thrust is like the tongue is looking for somewhere to go and there's no room. A tongue thrust in an adult, what you get is, I didn't mention this when you were talking about the physical exam, tongue scalloping. Scalloped edges on the tongue. That finding in an adult in and of itself is about 70% predictive for obstructive sleep apnea, because what that means is while they're sleeping, their tongue is pushing against their teeth and that's what's making those little indents on the tongue. What a tongue thrust says to me, and again, I think the myofunctional therapist would say this too, is that there's not enough room for their tongue to either sit down on the floor of their mouth or on the roof of their mouth. The bony structures are too narrow and now the tongue is trying to find somewhere to go to open up the airway. You'll see these teeth that get angled outwards. Instead of being straight up and down, they get pushed out because your body's trying to breathe. Then again, that's why you're saying when these orthodontic problems, it's like, "Well, why is it like that? Why did it get that way?" You can turn the teeth in and make it look pretty, but you haven't fixed the problem.
……
[Dr. Gopi Shah]
Are a large percentage of your patients getting sleep studies? Are you doing home sleep studies or lab sleep studies?
[Dr. Colleen Plein]
I have a pretty low threshold for sleep studies. We do mostly home sleep tests. What I'm really looking for is the designation between the people who have really severe sleep apnea who definitely need a CPAP or something like that in the meantime. It's helpful too sometimes in the younger patients, the women. You'll see these low AHIs, seven, eight, but I think we're accustomed to thinking of, again, sleep apnea in the traditional context of like, "Well, yes, an AHI of seven, eight is not going to kill you and give you a heart attack at age 55," but it's still going to give you all these other sequelae. Being tired, concentration.
There isn't a good correlation between the severity of sleep apnea and the symptoms. I would never use a normal home sleep test as a reason to say, "Don't address this." I also like to look at the pattern because sometimes you'll see the pattern. We get this little printout of the position and the oxygen saturation. You'll see, it'll be fine, fine, fine, then about an hour, hour and a half in, all the events will start and then the person will roll over and they'll stop. Then 20 minutes later, they'll go on their back and it'll all start again. You can show them that, "As you go into your deepest, most restorative sleep, your sleep is getting interrupted. This is why you feel like crap all day long."
…….
[Dr. Colleen Plein]
It's much easier to understand with a picture, but essentially it's the Bernoulli principle applied to the human airway. You've got two fixed segments, so in this case, your nose and your trachea with a collapsible segment in between them, which is the pharynx. There's a pressure differential between the nose and the throat or between-- we'll call it the upper airway and the trachea. At a certain point, there's a pressure, they call it the Pcrit or critical pressure where there's enough of a differential where you cause collapse of the middle segment.
The more pressure upstream, the more likely that segment is to collapse. The pressure, and the force of breathing through your nose is much less than the pressure and the force that you can breathe in through your mouth. This is why mouth breathing and sleep apnea, it's not just the tongue, but it makes the pharynx actually more collapsible because you're bringing air in at a higher speed and a higher pressure, which actually causes that collapse of the pharynx. This is why the switch from mouth breathing to nose breathing actually helps keep the airway more open.
Nasal breathing gets you better pharyngeal patency than mouth breathing, which sounds really weird, but it's true because you're not creating that vacuum effect exactly.
Chronic Mouth Breathing Treatment
Treatment for chronic mouth breathing involves a range of non-invasive and more advanced options. Myofunctional therapy, often provided by certified therapists, focuses on retraining breathing patterns and is a key approach for patients of all ages, although access can sometimes be limited due to cost and availability. Dentists, particularly those trained in craniofacial pain, are also crucial in addressing related issues like TMJ and bite alignment. They may use oral appliances to open the airway and improve breathing without pulling the jaw too far forward, which can cause discomfort.
For nasal issues, topical treatments like nasal steroids and antihistamines, combined with nasal irrigations, help alleviate congestion. Intranasal devices, such as Breathe Right Strips or silicone dilators like "mute," can physically open the nasal passages. Mouth taping at night is another strategy used to encourage nasal breathing, especially post-surgery. In some cases, dietary changes—such as reducing gluten and dairy—may help decrease nasal inflammation, though this can be challenging for some patients. These non-invasive interventions are designed to address the root causes of mouth breathing and are often used in combination for the best outcomes.
If non-invasive options are not enough, patients may eventually need surgical solutions.
[Dr. Gopi Shah]
Your myofunctional therapists, are those usually speech pathologists?
[Dr. Colleen Plein]
Yes. It's actually its own classification, its own certification. It's annoying because sometimes it's hard to get insurances to pay for it or it's a cash-pay thing. Myofunctional therapy is its own field and they're hard to find. Good ones are hard to find. We need more of them for sure. I'm sure with Googling or asking people, especially if you talk to people who are a little more tuned into this world, they will know who to send people to.
[Dr. Gopi Shah]
Segwaying from that, you refer patients to myofunctional therapists. Are there any other providers that you're working with? Let's say you've already optimized the nose as much as you can and they're still mouth breathing, or let's say they are really resistant to any sort of procedural or surgical intervention, or maybe they're not a good candidate or for whatever reason, how are you utilizing other services and colleagues to help? I know we talked about sharing patients with some of the dentists.
[Dr. Colleen Plein]
Sure. A good dentist and a good sleep dentist is invaluable. This might be a little too into the weeds, but when you talk about making oral appliances, there's different ways to take the bite position that you want them in. The classical thing that most sleep dentists do is they use this instrument called a George Gauge, which is basically, "How far can I pull your jaw forward? Just pull it as far forward as I can." That doesn't work and it gives people pain.
You want someone who's going to take the bite in a proper way. It's called the synetic bites, but it's in a proper position that is a more functional position that actually still opens up the throat significantly, but it's not necessarily just the chin all the way forward. There are physical therapists who work a lot with TMJ and TMJ-type problems and they can be very helpful. The dentists that I work with are-- there's two competing schools. There's the American Academy of Oral Facial Pain and the American Academy of Craniofacial Pain, but they treat patients very differently.
The people I work with are all associated with the American Academy of Craniofacial Pain. If you look for providers who have that sort of background, that sort of training. Luckily from what I found, it's becoming more and more of a thing in the dental community. They're doing a lot of good advocacy to try and raise people's awareness of this because a lot of times dentists will be the frontline people who are recognizing these problems. They'll see the tongue scalloping, they'll see the grinding, they'll see the high-arched palate, they'll see the giant tonsils and they can be the first ones to direct these people to, "There's a problem here, let's get it addressed."
Then there are people who actually manage the temporomandibular pain. The person I work with the most is a dentist, but he does decompression therapy and other things to help relieve pain. Nasal stuff, obviously Breathe Right Strips are great. If you have a problem getting Breathe Right Strips to stay on, there are a variety of intranasal silicone appliances. One is called a mute, like the mute button on the remote control. It's a little intranasal dilator. I recently saw something called Hale, which is supposedly designed by an ENT. It also sits in that nasal valve area, opens everything up, obviously maximizing topical treatment inside the nose.
Intranasal steroids, combining that with intranasal antihistamine if needed. Allergy management, if that's part of this, immunotherapy, nasal irrigations. Then also there's actually, believe it or not, I was very surprised to learn about this, how much the diet can actually influence nasal congestion. I've seen before and after scans of people who actually managed to go gluten-free and there's a humongous improvement in their nasal mucosal inflammation. My dental colleagues will tell people, "Avoid gluten and dairy." I tell people, "Look, that all sounds nice in theory, but it's very difficult to do."
I know lots of people, probably including myself, who would choose nasal surgery over having to live the rest of their lives without gluten and dairy. There's limiting benefit to all of these things, but there's always non-invasive options.
[Dr. Gopi Shah]
The other thing, I can't let you go without asking you about the mouth taping. What do you think about that? Putting tape across the mouth at night to make you breathe through your nose.
[Dr. Colleen Plein]
It's a thing and it works, to an extent. I hear stories about people who have done mouth taping and they had horrible congestion, and the more and more they did it, their congestion improved and great. That's awesome. It probably helps. It is something that I tell my patients to do post-operatively once they've healed. Anytime I'm treating a snoring patient, I always tell them, "Step one is I have to get you breathing through your nose. Step two is I have to get you to close your mouth. Sometimes you automatically close your mouth and sometimes you don't."
This goes back to that, "Is it habit?" My first thing after they're about four to six weeks out of nasal surgery, they're pretty much healed, I will have them start mouth taping and there's a variety of different products you can use for this. I just tell them to use regular medical tape. You don't need a very large piece. Put it on about 15 minutes before you go to bed at night so you get used to the feeling. Then usually over a couple of weeks, you can train yourself to go the whole night with your mouth closed.
It works great for some people. I would say it's going to work better for people who have mild or sleep apnea and some people can't do it so I say, "Okay, well, if that doesn't work for you, then that's when it's time for an oral appliance, because an oral appliance is going to do essentially the same thing." It still allows you to breathe through your mouth, but it's going to stop the mouth hanging open, tongue falling back thing from happening.
[Dr. Gopi Shah]
I'm glad you went over the list of all the non-surgical options you can do because I feel like the hard part is the oral appliances and myofunctional therapy is cost. Most of it's not covered. Like you said, there are resources that are difficult to find. You have to find a myofunctional therapist that's in the area as well as a dental colleague that you can work with. Again, mostly it can be cost-limiting. In terms of age, granted, we do topical nasal steroids phase, topical antihistamines, nasal rinses in kids, what's the youngest that you would do Breathe Right Strips for, and what's the youngest you would consider something like mouth -taping for?
[Dr. Colleen Plein]
That's a great question.
[Dr. Gopi Shah]
Are we thinking adolescents or are you thinking closer to 10?
[Dr. Colleen Plein]
Yes, I'm thinking more-- well, because again, you're not going to see the nasal valve issues as much I think in younger kids because they haven't had the skeletal growth to end up with that collapse if that makes sense. The mouth taping, I don't know. Obviously, that's something I would be very careful of in younger children for sure. I think they definitely need to be old enough that they could take it off themselves if they felt like they couldn't breathe. I would think maybe early adolescence for that. I don't know. That's a good question. I've never really thought about it in great detail.
[Dr. Gopi Shah]
I would agree. I think probably teens, 13 and up.
[Dr. Colleen Plein]
We don't want any mouth-taping-associated asphyxia events.
[Dr. Gopi Shah]
Then about the Breathe Right Strips. Do you ever have patients that are maybe history of cleft lip, craniofacial patients where the nasal obstruction, they've had the cleft rhinoplasty or they have an inherent reason? Do Breathe Right Strips help for those patients?
[Dr. Colleen Plein]
Breathe Right Strips have never hurt anybody. That's the nice thing about it. These are all non-invasive things that you can try. Also there's a variety of nasal dilator things because I mentioned a couple, there's nose cones, there's all sorts of stuff. It's more about realizing that that's the area of obstruction and you need something to hold it open, basically. I don't see a lot of those patients, obviously. The great thing about it is it's all non-invasive.
Podcast Contributors
Dr. Colleen Plein
Dr. Colleen Plein is a practicing otolaryngologist in Milwaukee and Chicago.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Cite This Podcast
BackTable, LLC (Producer). (2022, September 27). Ep. 71 – Nasal vs. Mouth Breathing: Does it Matter? [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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