Hot Topic Blog - Oral/Pharyngeal Sensory-Motor, Orofacial Myofunctional, & Airway Information

RISING MALOCCLUSION AND WHAT TO DO ABOUT IT

What are the Causes of Malocclusion?

It’s widely accepted that the teeth and jaws are at the mercy of the muscles of the lips, cheeks, and tongue and that soft tissue dysfunction, or aberrant swallowing (and breathing) patterns are the major cause of malocclusion (Ramirez-Yanez & Farrell, 2005). Therefore, any factor leading to either soft tissue dysfunction or breathing dysfunction may lead to malocclusion.

Why is Malocclusion on the Rise?

There is no doubt malocclusion has risen since primitive times. And, malocclusion appears to be related to environmental factors. The fact that wild animals and more isolated populations of human beings do not exhibit much, if any, malocclusion indicates it’s likely to be linked to our modern way of life (Price & Nguyen, 2016).

It seems malocclusion is a multifactorial syndrome which has come about due to a number factors. Some have been listed below. These influences are all related to our modern ways of living and cultural tendencies. Essentially, the introduction of anything leading to aberrant swallowing patterns, poor posture, or dysfunctional breathing impacts the incidence of malocclusion.

Below are 10 factors occurring more often in modern than in primitive times. Therefore, these might explain why malocclusion is on the rise:

-Use of sedatives such as pethidine during labour

Maternal use of any sedative during labour affects the newborn infant. Pethidine half-life is much greater in a neonate than a mother (13 hours compared to 30 minutes). Thus, the infant spends some the first day of life under the influence of sedation. It has been shown that this has an effect on the infant’s ability to learn to suck properly. Therefore, the establishment of proper swallowing (and breathing) patterns becomes difficult. The first 20 minutes post-partum has been shown to be the most important time to establish proper sucking. Correct or incorrect early sucking patterns were shown to be of prognostic value for the duration and success of breastfeeding. Proper breastfeeding helps establish proper swallowing patterns (Righard & Alade, 1990).

-Separation from the mother’s skin immediately after birth

The Lancet study by Righard and Alade (1990) also showed that separation from the mother’s skin prior to the onset of the first feed negatively affected the infant’s ability to correctly suck. In fact, the combination of pethidine with separation from the mother’s skin had a most deleterious effect.

-Use of pacifiers during early childhood

Pacifiers (dummies) cause the infant to learn to swallow in a dysfunctional manner. Therefore, increased use of pacifiers frequently leads to increased malocclusion.

-Use of bottles during feeding

Bottles have a similar effect to pacifiers in that they have the potential to alter the normal swallowing pattern. 

-Mothers being too tired to feed infants easily

It’s not uncommon in our modern world for our mothers to be managing multiple commitments. Modern mothers often take on more than just mothering. They frequently run the home as well as a business or full time job. Mothers are likely to be more tired than they used to be, and many tell stories of having to breastfeed while half asleep and feeling incredibly stressed. At times, tiredness from modern pressures makes them get sick or have difficulties with lactation. 

-Soft, sloppy, and refined diets

When veterinarians tell us to give bones to our puppies so they can develop proper masticatory muscles and grow strong jaws, they are giving us sound advice. Compare this to the common foods eaten by young babies, and it’s clear to see we typically feed our young soft foods that are more sucked than chewed. Primitive populations ate highly-textured diets compared to the sloppy, nutritionally-devoid foods we often feed our modern babies. This allowed primitive populations to develop proper swallowing patterns and strong masticatory muscles which, in turn, led to well-formed jaws (Price & Nguyen, 2016).

-Poor nutritional content of modern foods

Prior to refrigeration and preservatives, foods were mostly fresh, seasonal, and diverse. Nowadays, foods can be months or even years old by the time we eat them. Furthermore, the food industry has altered our food sources to enable longer shelf life and higher yield. Whilst this has its advantages, it certainly comes with a health warning. One example of such a modification is cow’s milk. There is a substantial body of evidence supporting theories that proteins such as casein in milk may be a major cause of allergy and congestion. Consumption of high volumes of cow’s milk products is a modern phenomenon. Advertising relating to its benefits is supported by the huge marketing budgets of the dairy industry. And, it’s worth considering we are the only species that drinks milk after infancy and, certainly, the only species that drinks the milk of another species (Hill, Duke, Hosking, & Hudson, 1988; Stricker, 2000).

In fact, food that has been refined in any way has a greater chance of having poor nutritional content than a completely fresh, seasonal, chemical-free version. Moreover, the lack of diversity in our diet puts us at further risk of being over-fed but undernourished. This malnourishment is linked to an increased frequency of illnesses. In 10 years from 2001 to 2011, there was a five-fold increase in anaphylaxis from food allergy (Osborne, Koplin, Martin, Gurrin, Lowe, Matheson, ... & Allen, 2011).

However, related illnesses may range from the common cold, to ADHD, to congestion, to diabetes. Since illness often leads to a blocked nose and open mouth posture, it goes without saying that it may lead to malocclusion. A child who is frequently sick with a blocked nose and open mouth posture will be more likely to exhibit a vertical facial growth pattern. The tongue is supposed to be free to sit up high in the upper palate to stimulate proper growth of the maxilla. Mouth-breathing due to sickness or congestion leads to a low resting tongue posture.

-Habits leading to poor posture

Modern children are future chiropractic time bombs. Poor posture is a major symptom of a comfortable and sedentary lifestyle. Watching television or playing computer games whilst sitting on a beautiful soft leather sofa might be fun. However, it’s a recipe for poor core strength, subluxation of the neck, and resultant poor posture. Since posture affects breathing patterns and growth direction, it’s likely to affect occlusion.

-Increased stimulation leading to illness

Modern humans are over stimulated compared to their more primitive counterparts. Exposure to screen technology past the hours of darkness, such as television and I-pads, may lead to poor sleep due to suppression of the sleep hormone melatonin (Lunn, Blask, Coogan, Figueiro, Gorman, Hall, ... & Stevens, 2017). Good quality sleep is linked to improved health. Good health is linked to nose breathing (without congestion) and, therefore, improved occlusion.

-Increased sympathetic nervous system activity and increased respiratory drive (mouth-breathing)

All of the above have the potential to excite the fight or flight sympathetic autonomic nervous system. Prolonged and frequent excitation of this system likely leads to increases in breathing dysfunction, since increased respiration occurs during such events. This increased respiratory drive on a frequent basis may lock the child into a pattern of over-breathing or habitual hyperventilation. When this occurs the Minute Volume (volume of air breathed per minute) at rest increases. Once this becomes the norm for a child, an open mouth posture and habitual mouth-breathing occurs to allow the bigger volume of air to be breathed. Open mouth posture and low tongue posture affects craniofacial growth and jaw development (Souki, Pimenta, Souki, Franco, Becker, & Pinto, 2009; Abreu, Rocha, Lamounier, & Guerra, 2008; Izuka, Costa, Pereira, Weckx, Pignatari, & Uema, 2008).

Why is There a Need for an Effective Early Interventional Approach?

Malocclusion is not just about the teeth. The teeth are simply a symptom of an overall syndrome and are merely the tip of a very large iceberg. Jaw growth occurs throughout childhood with the majority of growth being completed before the permanent dentition is fully erupted.

Achieving close to maximum genetic potential for growth of the maxilla and mandible are not just important for straight teeth. These bones make up parts of the face and are gateways to the airway. Waiting for all the teeth to erupt until age 12 or 13 is condemning the child to a face that is potentially less symmetrical and an airway that is potentially smaller than it might otherwise have been. For these reasons alone, it makes no sense to isolate the problem to the teeth, and only act in the best interests of straight teeth.

Previously, phase 1 Pre-Orthodontics has been rejected by some due to the potential for relapse while waiting for the final eruption of the permanent dentition. However, many of the systems used for phase 1 have not focused on changing the orofacial myofunctional patterns at the same time as expanding the jaws and aligning the teeth. A better system would involve both correction of orofacial myofunctional causes and active expansion and alignment where necessary. Or better still, in the case of an oral restriction, such as a tongue tie, early correction using an inter-disciplinary approach is recommended by the Tongue Tie Institute.

The fact that malocclusion is more than just crooked teeth suggests that a system which works on all aetiological factors and co-morbidities of malocclusion is preferential. Therefore, involvement of a team of professionals working to establish proper function is an effective and efficient approach. This team may involve the following professions:

-Dentist or orthodontist to diagnose the condition and expand the jaws to make space

-Dentist or orthodontist to monitor treatment progress and to prescribe the treatment plan

-Oral myofunctional therapist to help train the muscles (lips, cheeks, and tongue) to function normally

-Bodyworker to assist with musculoskeletal compensatory co-morbidities such as altered neck posture

-Breathing educator to assist with correction of habitual hyperventilation and establishment of proper breathing patterns

-Allergist to identify causes of congestion and decide on appropriate management

-Otolaryngologist to assess whether management of enlarged adenoids and tonsils is necessary

-Speech-language pathologist in the event the malocclusion has led to speech difficulties (particularly likely when there is a tongue tie present)

So What Should be Done if Malocclusion is Suspected?

Early diagnosis and intervention is essential for complete treatment, so refer to a dentist or orthodontist who focusses on Pre-Orthodontics. Not all practitioners are the same and often have different training with exposure to different philosophies and modalities. Given that malocclusion is linked to dysfunctional swallowing and breathing patterns and given that it is not just a problem for the teeth - it’s a growth disorder - referral to a dentist or orthodontist who focusses on establishing proper growth as early as possible is essential. Do not accept a treatment plan which involves monitoring every 6 months until all the teeth have erupted. These plans are only given out by practitioners who only see the problem as a problem for the teeth. The jaws need growing now and the dysfunction needs correcting immediately.

How Can Malocclusion be Reduced or Prevented?

-Do everything possible to establish functional breastfeeding from day 1 of life. If there is a tongue or lip tie, get it diagnosed immediately and treated as early as possible. It’s functional breastfeeding which leads to functional swallowing and breathing patterns. See a qualified IBCLC (International Board Certified Lactation Consultant) to help with this process. If tongue tie surgery is needed, be sure to use a multi-disciplinary approach to care (dentist/oral surgeon, IBCLC, bodyworker, and others as appropriate). Ensure a thorough surgery is carried out by an experienced surgeon. In my opinion, the laser is the only way to achieve a complete release of all components of the restriction unless several incisions are made with scissors or scalpel (which would require sutures).

-Avoid non-nutritive sucking habits such as pacifiers at all costs. These create dysfunctional swallowing patterns.

-Avoid bottle feeding if possible. Bottles also create dysfunctional swallowing patterns leading to malocclusion. In our modern society where mums often have to go to work this can be very difficult. However, when it’s an option, avoid bottle feeding.

-Introduce healthy, fresh, seasonal, non-refined solid foods to your infant as baby teeth emerge. These foods encourage proper chewing patterns and avoid sloppy, refined foods.

-Promote proper core strength. Ensure plenty of tummy-time – aim for 30 minutes a day by 4 months of age.

-Encourage healthy play outdoors. Do not allow your child to use gaming or reading tablets excessively or sit in car seats for long periods of time as unhealthy posture will result.

-Do not allow any type of screens after dark (such as television or computers). This is to assist with proper sleeping patterns.

-Get the jaw growth and tooth eruption checked by a Pre-Orthodontic practitioner by age 5 years of age.

References

Abreu, R.R., Rocha, R.L., Lamounier, J.A., & Guerra, Â.F.M. (2008). Etiology, clinical manifestations and concurrent findings in mouth-breathing children. Jornal de Pediatria, 84(6), 529-535.

Hill, D.J., Duke, A.M., Hosking, C.S., & Hudson, I.L. (1988). Clinical manifestations of cows’ milk allergy in childhood. II. The diagnostic value of skin tests and RAST. Clinical & Experimental Allergy, 18(5), 481-490.

Izuka, E.N., Costa, J.R., Pereira, S.R., Weckx, L.L., Pignatari, S.N., & Uema, S.F. (2008). Radiological evaluation of facial types in mouth breathing children: A retrospective study. International Journal of Orthodontics (Milwaukee, Wis.), 19(4), 13-16.

Lunn, R.M., Blask, D.E., Coogan, A.N., Figueiro, M.G., Gorman, M.R., Hall, J.E., ... & Stevens, R.G. (2017). Health consequences of electric lighting practices in the modern world: A report on the National Toxicology Program's workshop on shift work at night, artificial light at night, and circadian disruption. Science of the Total Environment, 607, 1073-1084.

Osborne, N.J., Koplin, J.J., Martin, P.E., Gurrin, L.C., Lowe, A.J., Matheson, M.C., ... & Allen, K.J. (2011). Prevalence of challenge-proven IgE-mediated food allergy using population-based sampling and predetermined challenge criteria in infants. Journal of Allergy and Clinical Immunology, 127(3), 668-676.

Price, W.A., & Nguyen, T. (2016). Nutrition and physical degeneration: A comparison of primitive and modern diets and their effects. EnCognitive. com.

Ramirez-Yañez, G.O., & Farrell, C. (2005). Soft tissue dysfunction: A missing clue in orthodontics. International Journal Jaw Functional Orthopedics, 1, 351-359.

Righard, L., & Alade, M.O. (1990). Effect of delivery room routines on success of first breast-feed. The Lancet, 336(8723), 1105-1107.

Souki, B.Q., Pimenta, G.B., Souki, M.Q., Franco, L.P., Becker, H.M., & Pinto, J.A. (2009). Prevalence of malocclusion among mouth breathing children: Do expectations meet reality?. International Journal of Pediatric Otorhinolaryngology, 73(5), 767-773.

Stricker, T. (2000). Constipation and intolerance to cow's milk. Journal of pediatric gastroenterology and nutrition, 30(2), 224.

About the Author Dr. Dan Hanson, Holistic Dentist

According to Dr. Dan, "My biggest passion is to inspire others to become the healthiest version of themselves. I combine knowledge from my traditional dental degree, with my alternative personal health journey, to deliver a holistic approach to health. Nutrition and Functional Breathing are my biggest focus."

Dr. Dan graduated in 2003 from Charles Clifford Dental Hospital, Sheffield, UK. Since 2012, he has limited his practice to children's facial growth and prevention of orthodontic braces; adult jaw problems (TMJ); breathing retraining using the Buteyko Method; adult and child snoring, sleep apnoea, asthma, and congestion; infant and non-infant tongue and lip tie; and helping babies to breastfeed using the most modern laser techniques (for tongue and lip tie correction).

Dr. Dan says, “When a baby is able to breastfeed correctly, it is not only more comfortable for the mother, but it helps to establish correct swallowing and breathing patterns. This in turn can lead to better overall health, including reduced infant symptoms such as colic, less chance of speech pathology, and better jaw and airway formation. The tongue is an amazing muscle, which when allowed to function correctly, can set the body up for better breathing, better sleep and better health.”

Dr. Dan is co-founder of The Tongue Tie Institute https://www.tonguetieinstitute.com/ and of two clinics - Heal Dental Care on the Gold Coast and Myofocus in Melbourne https://www.myofocus.com.au/. He lectures internationally on the subjects of early childhood orthodontics and breathing dysfunction and has had several articles published in professional journals relating to these topics. His credentials include BDS Dentistry, 2003 and Buteyko Institute of Breathing and Health practitioner (MBIBH) since 2011. Outside of professional work Dr. Dan is very passionate about Men’s Work. He enjoys co-facilitating men’s groups and running workshops within his community.

Contact Information:

-To book a consultation at my Pre-Orthodontic clinic in Melbourne click here: www.myofocus.com.au

-To book a Skype consultation outside of Melbourne email: drdaninfo@gmail.com

-To learn more about breathing dysfunction download pre-recorded webinars at the link below:

http://www.drdanhanson.com/courses/recorded-webinars

Or for a free (part 1) version of the above webinars click here: Free webinar