|Sleep Apnea from an Anatomical and Developmental Perspective|
The nutritional, immunological, emotional and psychological benefits of breastfeeding should be enough to encourage mothers to want to breastfeed their newborn and for all health care providers to strongly encourage breastfeeding. If not, this presentation addresses even more benefits of breastfeeding that can have a significant impact on total health.
All that is needed to view this presentation is Adobe Acrobat Reader. Adobe Acrobat Reader is a free download from the Internet. I would recommend you print out this commentary in full, or at least the section(s) you are interested in, and read along as you view the presentation. The presentation can be downloaded and saved to your computer for faster viewing by clicking on the icon that looks like a “floppy disk” in the upper left corner of the Acrobat window once the presentation has opened.
Just “click” on theSection title heading to open each of the three sections.
Section A– 2.4MB – 68 slides
Basic anatomy of the newborn
Basics of breastfeeding
Obligate nose breathing
Impact of bottle-feeding, pacifier use, infant habits
– 2.9MB – 79 slides
Basics of swallowing
Consequences: Tongue thrusting, malocclusions
Reasons for collapse
Section C– 3MB – 123 slides
How breastfeeding reduces the risk of:
Obstructive sleep apnea (OSA)
Long face syndrome
Slide Number Commentary
A3 & 4 – Key points: Palate has nice rounded continuous curvature, tip of tongue is forward of the “gum pad” or mandible, eustachian tube (auditory tube) is above the soft palate. A tooth bud is already forming in the maxilla. These cadavers were estimated to be about 6 months into development so the epiglottis is not fully developed.
A5 – Same curvature of palate and forward position of tongue. Key points: Relationship of soft palate and epiglottis and Dr. Crelin’s comment that the “tongue is entirely within the oral cavity”.
A7 & 8 – Illustrations by Escott and Woolridge demonstrating peristaltic motion of tongue during breastfeeding. Key Points: The tip of the tongue stays in the same forward position over and past the gum pad throughout the act of breastfeeding. It is the peristaltic or rocker motion from within the tongue that moves the breastmilk. The tongue constantly protects the breast from the hard gum pad during the act of breastfeeding.
Another key point about breastfeeding is that all the peri-oral musculature gets involved. Breastfeeding is a complex process needing coordinated efforts by all the muscles of the mouth and jaw. Infants have to ‘work’ all the muscles during breastfeeding. Example: Farmers who milk cows by hand, have strong hands, arms and shoulders. Those who use milking machines, don’t!
A9 to 12 – Research by Dr. John Neil, an OB/GYN in Australia. Key points: Breastfed infants have a rocker (peristaltic) motion of tongue during breastfeeding. Bottle fed infants usually have a piston like action (I will refer to this later as a tongue thrust). The breast (nipple and areolar tissue) is drawn into the mouth to a distance that is equal to or less than 5 mm from the junction of the hard and soft palate (key to otitis media). Stronger suction is required during bottle-feeding.
A13 – The tongue motion learned during breastfeeding / bottle-feeding / pacifier sucking is continued into adult life. The action of the tongue during swallowing is critical to the proper development of the oral cavity, airway shape, and facial form. During a correct adult swallow, the tip of the tongue should stay forward and rest just behind the upper front teeth during the whole swallow. The rest of the tongue should go up to the roof of the mouth only and not exert any force on the teeth in any direction.
A14 to 18 – Rugae. Very important for act of breastfeeding. Rugae are like a washboard on the roof of the mouth. They help prevent the breast from sliding or slipping around. Slippage by the breast during breastfeeding on a smooth palate would cause friction and heat and possible discomfort.
A19 to 24 – Obligate nose breathing. Dr. Crelin did extensive research in this area. Topic covered more in presentation on SIDS in another presentation on this website. During the dissections I was involved in (A24), I found what Dr. Crelin had predicted. Key points: At birth, the epiglottis and soft palate touch during quiet respiration with the mouth closed. During breastfeeding, the larynx elevates which allows the epiglottis to interlock with the soft palate. This allows the newborn to breathe and swallow at the same time – something the adult human cannot do. The term “obligate nose breathing” may not be the best term to use, because a newborn is not “obligated” to breath through the nose, it just makes it easy to breath and swallow at the same time during breastfeeding. If the nose in congested, the newborn can breathe through its mouth – but that leads to other complications like long face syndrome, otitis media and decay.
A24 – VERY IMPORTANT KEY POINT: As the tongue drops back into the mouth from its normal forward resting position in a newborn, the epiglottis naturally has to drop down into the throat. As the distance between the epiglottis and soft palate increases, the tongue base acquires a position where it can drop back and block off the airway – causing possible death by SIDS or OSA.
A25 – Picture A24 was altered by elevating the epiglottis to show how the epiglottis could interlock with the soft palate. However, this only happens during the act of breastfeeding.
A26 to 29 – These 2 cadavers (Siamese twins) were estimated to be about 6 months into development. Epiglottis does not appear to be fully developed. A27 was the twin of A26. Since the epiglottis was not fully developed, the dissection from behind shows more tongue than if the epiglottis had been fully developed and actually touching the soft palate. A28 was altered to show the relationship if the epiglottis had been elevated. Key Point: Note how breastmilk flows around the epiglottis, which is protecting the inlet to the larynx. A29 has been altered more to help visualize the direct connection from the nasal cavity to the larynx. It also shows how the tongue is blocked from entering the oropharynx while in this position.
A30 – Key points: In an adult, or in an infant where the epiglottis has descended, the posterior 1/3 of the tongue is the anterior wall or the oropharynx. This fact puts the individual at risk for the tongue dropping back and blocking the airway, putting the individual at risk for suffocation – be it either SIDS or obstructive sleep apnea (OSA). Note the point of insertion of the tongue – on the lingual (inside) surface of the mandible. IF the mandible is retruded (pushed back) in ANY individual, it puts that individual at risk for having a smaller than normal airway – increased airway resistance to breathing – and possible blockage of the airway resulting in SIDS or OSA.
A31 to 38 – Bubble palates. As a general dentist, I have never seen a bubble palate except in dissections. I have only learned about bubble palates from lactation specialist. Pictures A32 – 34 show bubble palates. It is fairly easy to visualize how pressure from the tongue has forced the palate up, forming a “bubble”. It is also easy to visualize how an infant with a bubble palate would have difficulty breastfeeding, since the breast would not be supported on the top side during compression of the breast. This might also explain why some infants “click” while breastfeeding (breast going up into the space and then clicking when it drops out of the space).
Pictures A35 to A38 are courtesy of Catherine Watson Genna, IBCLC. She is currently doing extensive documentation of bubble palates and will hopefully share her research in the near future. She is finding a high correlation between bubble palates and tongue-tie and micrognathia (retruded or pushed back lower jaw).
Following is part of a letter I received from Lisa Marasco, IBCLC describing palates:
“A “bubble” palate is a high spot, often the size of a finger indentation, that has a back rim. It may extend width-wise from gum line to gum line (wide bubble), or be a smaller indentation in the middle. As you feel the infant palate, your finger will go up, come down the back side or “wall”, and then have to go “around and past” that wall to reach the juncture of the soft palate. Your pad-side up finger loses contact with some of the hard palate in order to reach the soft palate. Babies often gag when you go past the bubble because they are not comfortable with it, even though it is normal to draw the breast back to that juncture, usually about 1.25-1.5” deep. Babies with bubble palates tend to rearrange themselves on the breast into a shallow latch, and I use pacifying on a properly placed finger to help de-sensitize them to deeper placement, sneaking back slowly.”
Other types of palates:
The “reference” palate has a smooth contour front to back, changing from hard to soft palate without too much change in terrain.
A “high” palate is when this whole cavity is very high making compressing the breast against this area more difficult.
A “channel” palate can be caused by long-term use of a nasogastric tube.”
Key questions: Do bubble palates resolve themselves over time or do they develop into high palates? What causes them? Hopefully Genna will find the answer. High palates have a great impact on breathing and total health. How many infants are born with high palates? Are they due to trauma during birthing? Will high palates resolve themselves if the infant is breastfed?
A39 to 45 – Ankyloglossia (tongue-tie) Key question: Why do tongue-tied infants have difficulty breastfeeding and why does it cause sore breasts? Answers are quite simple – the tongue cannot extend over the bony gum pad nor can it reach the roof of the mouth. If the tongue cannot extend over the bony gum pad, the hard gum pad hits directly into the bottom of the breast. The breast is usually cushioned from the bony pad by the tongue. If the tongue cannot extend up to compress the breast because of the tight frenum, the infant cannot effectively compress the breast. Tight frenums will be covered later.
A46 to 49 – Pictures taken by Dr. Weston Price in the 1930s. He visited tribes in isolated areas around the world that had not been exposed to industrialized ways. He found ideal facial forms, beautiful smiles, teeth free of decay and near ideal occlusions (bites).
A50 to 57 – I found skulls in museums from prehistoric times with similar ideal features. Modern is not always better! No fluoride was available to those individuals yet they were free of decay. See presentation on infant decay elsewhere on this website. Some teeth had been knocked out due to handling. Many skulls had flat teeth because of course diets, however.
A59 & 60 – Key slides: Both pictures try to show a state of “neutrality”. There are no excessive or abnormal forces on any structures in the oral cavity. Teeth erupt into a natural “neutral zone”. If abnormal forces occur in this neutral zone, teeth will erupt crowded and crooked. Muscles always win out over bone as far as forces are concerned. The tongue and cheeks determine where the teeth will move.
A62 – A vacuum created by excessive sucking can have a significant impact on the development of the oral cavity, airway and facial form.
A63 – Key illustration: Note how an object firmer than the breast can: elevate the palate, displace the tongue downward, which in turn can exert forces to push the lower jaw out. The strong sucking action implodes the cheeks forcing the upper teeth inward.
A64 –Very key illustration: Depending on the firmness of the object, the tongue could be driven back into the mouth prematurely – driving the epiglottis to an inferior position before its time. This could expose the infant to a higher risk of otitis media and SIDS. This situation is the reverse of being tongue-tied – the tongue drops back because it is more effective to squeeze the bottle (and less painful to the tongue) with the bony gum pad. The distalization of the tongue can also elevate the soft palate – infringing on the space for the eustachian tubes. This leads to what Dr. Neil calls a “piston” action of the tongue and which I refer to as a tongue thrust. Leverage from the object can distalizes the mandible and at the same time and flair the upper teeth. Any object placed in the mouth excessively (other than the breast) can have significant consequences on tongue action and the development of the oral cavity, position of teeth, shape of the airway, and facial form.
A65 – Illustration of above. Note how an elevated palate decreases nasal space and creates a high palate. Narrowed upper arch leads to a cross bite malocclusion.
A66 & 67 – Actual example of above illustration.
B3 to 10 - Thumb sucking: Thumb sucking is a natural way for the infant to learn how to suck and pacify itself. It is not a problem as long as it is not excessive. Many times, however, you do not know what excessive is until a problem arises. B5 illustration was explained on slide A64 (pacifier). B6 illustrates how a retruded chin drives the tongue back into the oropharynx.
B36 – Excessiveness is a function of: how intense the infant sucks on an object, how often he sucks on it during the day, and for how long he sucks on it – could be months or years.
Articles mainly support the position that if an infant is breastfed and has access to the breast at times of stress, he/she is less likely to have to suck on other harmful objects and therefore less likely to have a malocclusion. The key to the importance of breastfeeding from an oral cavity development perspective, is that breastfeeding develops a proper peristaltic / rocker action of the tongue. This correct / normal motion of the tongue is what dictates the shape of the oral cavity, the occlusion, airway and facial form. The development of other peri-oral muscles involved with breastfeeding are also very important.
B43 – Cup-feeding is a good alternative to bottle-feeding, especially for moms who pump during the day while they are at work and breastfeed when they are home. This helps maintain the integrity of the swallowing pattern.
B45 to 47 – TEST YOURSELF: See if you are a tongue thruster (reverse swallower / abnormal swallower, etc.). Close your eyes and concentrate on what happens to your tongue when you swallow. Place the tip of your tongue on the roof of your mouth just behind your upper front teeth (you might be able to feel a little bump or papilla up there); make a nasally sounding ‘N’ sound (like the ‘n’ when you say the word ‘noise’), close your mouth, and then swallow. The tip of your tongue should stay stationary in the same spot, and the rest of your tongue should go up to the roof of your mouth as illustrated in B47. That swallow was learned during breastfeeding days. Your tongue should NOT push into, or between your teeth, in any way. I generically call everyone who cannot swallow as described above, a tongue thruster. If you are a tongue thruster, you have a good chance of relating to some of the things I describe in this presentation.
B48 to 59 – Consequences speak for themselves. There is a high rate of relapse in orthodontic cases because the orthodontist does not address the main cause of the malocclusion, such as: a tongue thrust, tongue-tie, large tongue, large tonsils, or obstructed airway.
B60 – I feel the American Academy of Pediatric Dentistry needs to re-evaluate their position on how breastfeeding impacts oral health, dento-facial growth, and dental decay as it relates to breastfeeding.
B61 & 62 – When I evaluated prehistoric skulls (approximately 600) I discovered they had very good occlusions, very little decay, and good skeletal (facial) form, as did Dr. Weston Price and others. Doesn’t it seem ironic that today, when 75-85% of children in western countries use pacifiers, that 89% have some occlusal disharmony. I do not think it is a coincidence.
B63 – Largest increment of craniofacial development occurs within the first 4 years of life. It is critical to understand the importance of this early development. See following illustrations.
B64 to 76 – Facial form. Natural beauty has been shown to have a proportion ratio of 1.618 / 1.0. Architects use this ratio when they design building. Dentists use the ratio when designing beautiful smiles. I encourage you to read more of Yosh Jefferson’s works on beauty. Illustrations show the proof.
B77 – There are several reasons for the collapse of the oral cavity and airway space. Each has to be considered separately. I place refined sugar on the list out of respect for the research of Dr. Weston Price, who felt nutrition (as do I) was a major factor in development.
C3 – Obstructive sleep apnea is a major medical problem in the USA today. It is grossly under diagnosed and under treated. It has many side effects and is potentially deadly. I believe it is a major component of many health problems today.
C4 – The key to life is one’s ability to breathe. If you cannot breathe, you die. Variability in health can be directly related to any resistance to airflow.
C5 – Opening the airway is the most critical part of emergency care.
C6 – My most prized slide. It illustrates what the oropharynx (throat) of a healthy individual should look like. This is a 90-year-old gentleman who only takes one small pill a day for a stomach problem. This is the way everyone’s throat should look like. Check out the throat of your loved ones. This picture also demonstrates the function of the uvula in an adult – to funnel mucous down the middle of the throat. In a newborn, the main function of the uvula is to interlock with the epiglottis so the infant can breathe and swallow at the same time.
C8 & 9 –This is the main point of my total website: I have been researching the collapse of the oral cavity for close to 30 years. I have been involved with sleep apnea research for about 10 years. I have never fathered a child and have no direct link with the breastfeeding industry (except to give an occasional presentation). I have no reason to support breastfeeding except for the belief in my research that demonstrates breastfeeding is the key to better health. My research is totally unbiased. I have researched many different paths. Since I am a full time general dentist who has totally funded this research, I just do not have the time or funding to do comparative “scientific” research.
From my research, I conclude: Breastfeeding, for at least one year, is critical for the proper development of the oral cavity, airway and facial form. For this proper development, the peristaltic / rocker motion innately learned by the infant, is the key issue. Breastfeeding also develops the total peri-oral musculature. This is also critical. Since the largest increment of craniofacial development occurs within the first 4 years of life, how we develop in those early years impacts us for life.
The presentations on this website demonstrate how infants habits impact the development of the oral cavity and create the malocclusions not found in prehistoric times. The malocclusions discussed in this presentation are directly linked to causes of obstructive sleep apnea - as discussed in the next slides.
C10 to 12 – I rank this formula in the same category of importance as Einstein’s formula of relativity. I believed in this formula long before it was very published. It is a formula very few people know about or understand. It is the key to better health for all – IF the health care industry will accept it. Key point: There is no ideal treatment for OSA. The key to treating OSA is to prevent it in childhood days – by preventing the malocclusions and conditions that cause it – or at least treating the condition at an early age before the mid-palatal suture line starts to fuse. Once the suture fused, expansion of the pterygoid plates are nearly impossible.
C19 – Models showing a retruded, Class II malocclusion, with overjet. Remember that the tongue is inserted on the inside of the lower jaw, so when the mandible is in a retruded position, the tongue is also distalized and is infringing on airway space. The red arrows should be lined up for a proper Class I occlusion. C20 – Lower model has been moved forward to line arrow up for a correct molar relationship (Cuspids are not in correct Class I occlusion). Advancing the mandible in this way advances the tongue and helps open the airway. This is the principle on how oral appliances help reduce snoring and OSA.
C21 to 39 – Demonstrates the importance of sleep and breathing.
C23 & 24 – A high percentage of children with ADHD or behavioral problems may be over medicated for their conditions. Addressing their airway and sleeping behavior may be a possible solution.
C25 – Removing tonsils or expanding a high palate may be all that is necessary to resolve a bed-wetting problem.
C26 & 27 – Infants with growth problems may not be getting to Stage 4 sleep where growth hormones reach peak secretory levels.
C33 – My brother, who lives in Canada, had a stroke seven years ago. I believe his stroke was due to undiagnosed and untreated OSA. He is in a long-term care facility and will never get out. OSA impacted his life forever – and at a high cost for the health care system.
C34 & 35 – It is recognized that abnormal tongue activity is a factor in OSA. Some believe it is an inherited trait. It is if you are tongue-tied, but most abnormal tongue activity (tongue thrust) is a result of learned behavior.
C40– Long face syndrome: TEST YOURSELF: Hold your nose and see what happens. You will soon have to open your mouth and breathe. As a chronic condition, obstruction in the airway will cause mouth breathing and an open posture of the mouth. Over time, this open posture can lead to a ‘long face’.
C42 & 43 – An example of a compromised airway of a 12 year old. Despite the fact that the boy was always falling asleep in school, was disruptive in school and getting bad grades, the pediatrician would not recommend removal of tonsils because he had not had three episodes of tonsillitis within a year (the criteria that insurance companies use for paying for the procedure). I was finally able to have the mother take him to an ENT who understood about airway compromise. She removed his tonsils. There was a dramatic improvement in his behavior, attitude and grades.
C44 to 46 – Can you tell the difference in ages between these three throats? I referred the 27 and 30 year olds over for sleep studies – they both had OSA. I also suspected the 7-year-old also had sleep disordered breathing but his pediatrician would do nothing about it.
C47 to 50 – 14-year-old with a long face. In C47 his mouth is open and he is mouth breathing. C48 shows his compromised oropharynx. He is also a tongue thruster. Another reason for a tongue thrust is that the individuals throat is so compromised, that the individual learns that by pushing the tongue forward, he can breathe better.
C51 to 53 – Note open lip posture of this youngster that is similar to the lip posture of the excessive thumb sucker covered in the ‘facial form’ section.
C54 to 57 – Adult lady with a long face and OSA. She has a classical forward angulation of the head and slant of face. People with long faces and a forward angulation of the head have a tendency to having sore necks and headaches. This is due to the stress of the muscles holding the head forward instead of over the spinal column. The head angles forward because that position makes it easier to breathe – just like in CPR when you point the chin up to open the airway. These individuals maintain that position by just bending at the neck to maintain an upright posture.
C59 & 60 – I believe not receiving the mother’s immune system through breastmilk is the main reason for inflamed tonsils, but there are other reasons as well. Anything that will make an infant sick or lead to allergies can inflame the tonsils. Enlarged tonsils are probably the major contributor to long face syndrome.
C61 – SIDS – This is a summary of the main presentation on SIDS at another place on this website. Key points: The position of the epiglottis and soft palate. This relationship protects the tongue from falling back into the oropharynx for the first 4 to 6 months of life. This allows the brain stem time to mature until the brain can respond to any infringement in the airway. Bottle-feeding, pacifier use, etc. can possibly interfere with this relationship by forcing the tongue back into the mouth – which in turn forces the epiglottis down the throat – exposing the tongue to the back of the throat. In adult sleep apnea, the tongue falling back into the oropharynx by gravity is a major contributing factor to OSA (C66). I believe it is also one of the ‘true’ causes of SIDS.
Premature infants are quite susceptible to SIDS. This may be due to an underdeveloped epiglottis, which does not have the size to touch the soft palate.
C74 to 104 – Otitis media / Pacifiers: There is a full presentation on otitis media elsewhere on this website. Key points: Dr. Neil’s research discovered that during breastfeeding, the breast stretches / extends to the junction of the hard and soft palate or short of it. During breastfeeding, there is no pressure exerted on the soft palate that would force the soft palate up into the chamber where the eustachian tube is located. During the period of obligate nose breathing, the interlock of the soft palate and epiglottis also protects the passage to the eustachian tubes. The above is not true during bottle-feeding. Depending on length, the bottle nipple could force the soft palate up if it was long enough, but the key point during bottle-feeding is the action of the tongue. The tongue is driving back and up – by either forcing the tongue tip back into the mouth, or the tongue is forced back to protect the airway from too much flow from the bottle. This in turn forces the soft palate up and infringes on the space around the eustachian tubes. Improper firing of the muscles controlling the eustachian tubes can also be a contributing factor to otitis media.
C83 – Gravity is also a strong contributor to otitis media. Any infant fed on its back is at risk for fluid getting into the eustachian tubes. Even during breastfeeding, I would encourage the head be slightly elevated – best if mom was in a sitting position.
C105 to 117 – Abfractions: I have been researching these of 30 years also (along with abnormal tongue activity). Many dentists believe abfractions are due to brushing your teeth too hard. Many articles espouse the same thing. Even this short presentation on the topic should be able to convince you that abfractions have nothing to do with tooth brushing. Abfractions are caused by abnormal lateral forces. These forces are the result of malocclusions and tongue thrusts that, I have hopefully convinced you, are due to infant habits. The posterior (back) teeth are not designed to withstand lateral forces. Example: If you bend a coat hanger back and forth with a lateral, side-to-side force, what happens? Over time, it breaks down and eventually breaks in half. Many of you who read this have notches on your teeth near your gum line. These areas may be sensitive. These are abfractions. These notches are not due to brushing too hard.
C118 – Obesity is a major problem in the USA. I included this just for a point of interest.
C119 – This research could have major implication for the importance of breastfeeding.
It has taken 30 years of research and a full year to complete this website. As you can tell, I am a strong proponent for breastfeeding and total health. As a health care provider and a victim of cancer who has had his health care insurance cancelled, I know our health care system is in crisis. The youth of today need to be taught how to live healthy lives. The key is prevention and a healthy lifestyle. It all begins with breastfeeding.
I have done the best that I can. I am hoping others will pick up on the research that I have done, and move forward with it. I just do not have the time or funding to take this research to the next level. It is now time for me to step back and enjoy golf and walking the beaches with my lovely wife.
For Better Health!
Brian Palmer, D.D.S
Leawood, Kansas, USA