An increasing number of studies are helping us to become more aware of the effects of airway issues on our adult patients. Obstructive Sleep Apnea (OSA), Upper Airway Resistance Syndrome (UARS), and other Sleep Disordered Breathing (SDB) issues have found their way on restorative problem lists.

SDB was the subject of an article last year by Dr. Steve Carstensen: "Sleep Apnea: A History of Present Illness." Relationships have been proven to exist with airway issues and high blood pressure, cardiac disease, depression and anxiety. Dental issues can include tooth wear from bruxism, tooth erosion from acid reflux and occlusion changes that can become severe and difficult to restore. Another consideration to keep in mind regarding the airway is soft tissue. Dr. Kevin Kwiecien addressed this issue in his article “That’s a Lot of Soft Tissue to Look At, But It’s Our Responsibility.”

It appears that the typical “stereotype” of the OSA patient is no longer so definite. An overweight male who snores may not be the only person we should question or screen for airway and sleep issues. “Skinny” women can have sleep related airway issues too. Even less obvious to us is the young patient, the one we could possible help reduce future risks of airway issues that can occur with aging. Children have a very low threshold of AHI (Apnea Hypopnea Index). With sleep issues they are not immune to the affects of bruxism and enamel erosion that we see in adults. Their school performance and behavior can be negatively influenced by sleep disorders.

As dentists, screening young patients for airway and breathing issues is certainly not new. Mouth breathing, daytime tiredness and “stuffy nose” have long been indications for a referral to an ENT for evaluation of adenoids and tonsils. Orthodontic literature also describes long lower face, vertical excess skeletal patterns associated with greater risk for lip incompetence and mouth breathing issues. All these indicators merit a close watch on airway and guiding growth in a more favorable direction.

An additional measurement for airway risk that dentists can add to their screening in children is palatal or intermolar width. Keeping in mind that the roof of the mouth is the floor of the nose, a narrow palate can affect the upper airway. The average inter molar width is measured from the lingual gingival margin of the upper first molars, where the lingual groove meets the gingival margin. The average width range for the permanent dentition is 35-39 mm.1 An easy addition to your exam routine is to screen for this is by using a cotton roll which measures 35-36 mm. Since it is already on the hygienist/assistant’s tray during a prophy it is an easy tool to help you see if any further investigation is indicated. (Figure 1)

airway and dentistry figure 1
Figure 1

The presence of a cross bite is often the diagnostic criteria for palatal expansion which can be too limiting. In the case below the intermolar width was 25 mm. The primary teeth were severely worn and, as in adult tooth wear, is another indicator there could be airway issues. (Figure 2)

airway and dentistry figure 2
Figure 2

Expansion was completed early at age eight before the full eruption of the upper permanent incisors. The final alignment was completed and intermolar width stabilized at 35 mm. Not only was space for eruption achieved, no wear of the permanent incisors is noted. (Figures 3,4,5)

airway and dentistry figure 3
Figure 3
airway and dentistry figure 4
Figure 4
airway and dentistry figure 5
Figure 5

Try expanding the screening of your young patients for potential airway issues, to include palatal width. An improvement in patient health and well-being and reducing risks of tooth wear and future crowding, make it worth the extra step.


1. Orthodontics and Dentofacial Orthopedics, James L. McNamara Jr. and William L. Bruton

Donna J. Stenberg D.D.S., M.S., P.A. Spear Visiting Faculty and Contributing Author.


Commenter's Profile Image Michael Weisbrod
April 8th, 2015
Great reading! What age should we start the screening, and at what age would it be appropriate to make an orthodontic referral? What risk factors should we look for to consider a referral to the ENT? I look forward to doing more research and learning more! Thanks Donna!
Commenter's Profile Image Donna Stenberg
April 10th, 2015
Hi mike, so glad you are still involved with spear through the digital suite. As a screening the AAO recommends age 7 for orthodontic screening in general. In your practice you can measure the palatial width after the eruption of the upper first molars to access palatal width. Observing any wear patterns will also give you more information. Palatal expansion is easier in the age range of 8-10 but with early tooth development you might need to start earlier so you have stable primary molars for your expander support. Sending a few photos to your orthodontist can create a more individualized referral for each patient. The risk factors for an ENT referral I will screen for mouth breathing, ask parents if their child snores, do they have allergies, and look at the tonsil area for any obvious tissue blocking the throat. Your orthodontist can also observe the airway and adenoid area on the cephalometric image. This is another excellent collaborative discussion to have with your orthodontist or at a study club meeting. Thanks for the question Mike!
Commenter's Profile Image John Dano
April 11th, 2015
Mike The present orthodontic recommendations/standards are behind the times, IMO. By the time a child is 7yo and is already into the early mixed dentition, you may have already missed intercepting some G&D issues. It is also my opinion, that most dentists and orthodontists have very little training in screening their patients for UARS, SDB and OSA, all which are often present to varying degrees in a child and significantly result in unfavorable growth pattern of the lower 3rd of the face resulting in narrowed and highly vaulted palates, poor oral tongue posture, deep bites, retruded mandibles, excess maxillary vertical growth due to lack of lip seal, forward head posture to facilitated mouth breathing, long faces, as well as possible affecting neurologic brain development and behavioral issues that can lead to a diagnosis of ADD and ADHD and other syndromes etc... A great website with multiple links on this subject but also a great video to watch on this subject can be found at and click on the video link titled "Finding Conner Deegan". All children should be screened for TOTS- (Tethered Oral Tissues), particularly a tethered tongue by their Pediatricians at birth. Unfortunately, most pediatricians have very little training in assessing for tethered oral tissues and treating them and thus so many children are allowed to grow with tethered tongues as well as the other tethered oral tissues. Probably the leading cause for an infant to not being able to properly breast feed is that they are unable to properly latch to the mother's breast in order to suckle is due to a significantly tethered tongue. It is also interesting that a tethered tongue also is a leading cause of gastric reflux in a infant due to the infant swallowing air due to dysfunctional swallowing resultant to a tethered tongue which then causes the stomach to fill with air and when the air gets released from the stomach it brings the food with it. A great resource on TOTS is Larry Kotlow, a pediatric dentist in Upstate NY at his website, He has videos to show how to properly screen a child for TOTS. A good book to read on how we have negatively affected growth and development of our children in our modern society because we do not have our infants chew there food, instead they just swallow blended food is titled "Baby Lead Weaning" by Gill Rapley & Tracey Murkett. Another good book to read on the importance of breathing through the nose instead of mouth is "Close your Mouth" by Patrick McKeown. I can go on and on about his subject but it is clear that humans are growing larger physically overall but our oral cavity is growing smaller as evidence that hardly anyone has room for the 3rd molars anymore and that it has become more the norm later in life that we have OSA than not.