Hello, I'm Dr. Dave Federici, and I've been practicing dental sleep medicine in my general dental practice for 11 years. Today, I'd like to demonstrate a simple nasal evaluation that can easily be added to your comprehensive dental sleep medicine exam. First, we have to remember that the nose has an important role in breathing. It functions to warm, moisten, and filter the air before it reaches the lungs. And as a dynamic system, it constantly adapts to environmental factors such as allergens and extreme temperatures. Those of you in the north might notice your nose responding to a bitter cold day. The nose may also function differently in response to hydrostatic changes that occur when going from upright and active to a reclining and sedentary body position. In other words, some individuals experience nasal resistance to airflow when they lay down to go to sleep. We also know that nitric oxide is formed as inhaled air passes over the paranasal sinuses. As it reaches the lungs, it enhances pulmonary oxygen uptake via local vasodilation. In any event, studies have demonstrated that nasal obstructions and resultant mouth breathing may contribute to upper airway resistance and collapse. When treating patients with sleep-related breathing disorders, we also know that compromised nasal airflow can make it challenging for patients to comply with therapy. So the goal of a nasal evaluation is to screen for chronic, consistent, or intermittent nasal resistance. This will help guide our treatment planning and likely improve patient outcome. We begin with a validated nasal screener called a Nasal Obstruction Symptom Evaluation Scale, or NOS for short. It's available for use without licensing. The screener asks the patient to rate their experience with nasal congestion over the past month and results in a nasal obstruction severity score. In our office, this is accompanied by a brief patient interview to uncover more subjective data on nasal function. The screener uses congestion and obstruction interchangeably, but technically, congestion implies inflammation, whereas obstruction may be related to intranasal geography alone. For example, we'll ask, is your nasal congestion year-round or does it seem to be related to seasonal triggers such as yellow pollen season? Do you awaken with a dry mouth or catch yourself breathing through your mouth at night? Have you ever attempted to use nasal strips, lavages, or sprays to improve nasal airflow? Have you had any injuries or surgeries that could affect nasal breathing? Do you think you were able to breathe easily as a child? Do you have tonsils or adenomas removed? You might also ask a CPAP-using patient to describe the mask they were given, as we often see a full-face mask dispensed for people who tend to breathe through their mouths. We know that it is often difficult for someone with nasal resistance to use CPAP. Also, when designing an oral appliance, we'll want to be sure to accommodate their dependence on oral breathing. It may even be appropriate to include a referral to an ENT as part of our treatment plan. As we proceed to our physical evaluation demonstration, we know that our patient, Winchester, reports chronic nasal stuffiness when sleeping, and it's worse during allergy season. But this is less noticeable during the day. He's tried CPAP, but it was a source of sinus infections, and they had given him a full-face PAP interface to use. Before approaching him, I'll be watching for classic signs of mouth breathing. I'll make note of lip and mouth posture at rest. Does he maintain lip closure when not speaking? Does he have a dark under-eye shadow? Turn down lateral corners of his eyes? Or a narrow maxillary skeletal appearance? Or long lower facial height? Are his lips dry or chapped? All these findings will lead to a suspicion of a dependence on oral breathing. If we see these signs while the patient is upright and awake, we can assume it will be exacerbated at night in a reclined position with only physiologic control of airflow. On the other hand, if the patient has a normal score and the nose screener, and no outward appearance of oral breathing, I'd likely skip the functional testing I'll be demonstrating today. So, Winchester, you've responded on one of our forums that you routinely experience nasal congestion and you couldn't tolerate your CPAP. I want to evaluate your nose as part of today's examination. I'll explain as I go along. Will that be okay with you? Yes. Great. We'll start with three functional tests. The first is called the Rosenthal breathing test and determines your dependence on mouth breathing today. It only tests for how you're breathing right now, so it might be different when your body is reacting to allergens or you're reclined or sleeping. Please close your lips and just breathe naturally as you can. I'm going to time you for about a half a minute. You okay with that? Are you ready to go? Yeah. Okay. So, go ahead and close your lips and just take some normal, two deep breaths. Okay. I'm going to stop you a little short of the actual timing because I noticed that your lips opened up and it was becoming difficult for you, some effort for you to get the adequate airflow. This tells us that mouth breathing isn't just a habit for you and that at least today, your nose is too congested to supply the airflow you need, even when resting and sitting. The next test is also easy and we'll screen for something called vabular collapse. There is supposed to be enough cartilage in our lower part of our nose to prevent your nares from collapsing when you breathe in. If breathing in deeply closes the nostrils, even partially, you can imagine how that would make nose breathing more difficult. So I want you to close your lips and inhale deeply. I'll be watching to see if your nose starts to narrow here in the supralar creases on one or both sides. So go ahead and close and take some sniffs. A little bit more force now. Great. Thank you. I didn't see any collapse even with your larger breaths. Now one or more function tests before I start the exam. It's called the caudal maneuver and ENTs use it routinely. This time I'm going to take the stretch the skin on either side of your nose outward to see if a slight increase in the width of the part of your nose improves your experience of airflow. For this, all you need to do is breathe normally. Here we go. I'm going to take some breaths and I'm going to pull the tissue away to open up. Now I'm going to go just to one side for a couple of breaths and I'll go the other side. Excellent. Did you notice an improvement in airflow when I stretched out your tissues? Yeah, the right side felt the airflow was pretty good on the right side. The left felt a little bit clogged maybe because of allergies. Okay. Since you appear to have some congestion today, allergies on that one side, I'll try something called a nasal dilator. These come in all shapes and sizes and you can get them almost anywhere. It's something you want to try it when you go to bed on a congested day to see if it helps at all. It makes sense to try them even on days you don't feel congested because for some patients the congestion begins to develop after they've been reclined or for a while. So I recommend patients try them even if they don't report any awareness of nasal restriction because they may discover they increase airflow regardless. Some patients love them. Some patients report that they really don't help or just can't stand having something in the nose. So, okay Winchester, I'd like you to insert these dilators in your nose now. There's one for each nare and we're going to have the smooth side facing downward. Once you get it placed in there, take a couple good two, three deep breaths and tell me how you feel these dilators may have improved the airflow quantity coming through your nose. Are you starting to feel? Yeah, I'm starting to feel a difference. Definitely on both sides now. Okay. Definitely more clear. Great. Since you've shown some improvement, I'll send these samples home with you so you can give them a try at night. Just wash them with warm soapy water when you get up in the morning. Next, I'll be looking inside your nose. But before that, any more questions before we move on? No, doctor. Okay. Could you kindly take the dilators out of your nose, please? Yeah. Thank you. Excellent. When I recline the patient, I'm able to visualize the lower nasal valve more easily. I'll be looking for redness, drainage, or a deviated septum. Remember to keep in mind that inflammation could be temporary and driven by a virus or allergens. Some dentists use a device called a nasal speculum to help them see further into the nose. Other dentists use an instrument called a rhinometer that uses acoustic feedback to help visualize deep nose geometry. But as dentists, we can only report observation as part of a referral to a nasal specialist, so it's a matter of personal preference. I'll just be using my mirror and light today. It's also important to remember that we are generally only able to see the lower concha and septum, not the entire nasal airway. In other words, there could be a restriction that is just too high for us to see. This part of the examination will include oral findings as well, some of which may be related to nasal airway. I'll begin by inspecting the skeletal arch form and symmetry. We know that a collapsed, narrow, vaulted palate is often associated with a dependence on mouth breathing during growth and development. If you were to measure the distance between the palatal cusp tips of first molars, roughly 35-40mm would be considered a pretty normal finding. I'll also pull on upper and lower lips to determine if the patient's phrenum attachments align with their dental midline. From there, I would routinely just complete the comprehensive oral examination of both soft and hard tissues. I like to sit the patient back up before I share my findings, but some dentists prefer to discuss the findings as they proceed. Okay, Winchester, we're going to start our examination now. So what I'd like you to do is turn toward me. I'm going to be checking your midline skeletal, septum, nose. Could you open your mouth for me, please? I'm going to look at your palate and vault form, jaw shape. Excellent. Would you close your mouth down for me? Stay closed, please. I'm going to pull your lips back and evaluate your phrenum attachments. Excellent. Thank you. Okay, so Winchester has no facial asymmetry, no deviated septum, normal arch form, and palatal width. Based on phrenum attachments, Winchester's dental and skeletal midlines align. Before proceeding with any treatment, it is important to educate the patient on the negative effect of oral breathing on airway resistance and tendency to collapse. Loss of muscle tone in all stages of sleep will compound this. The benefits of physiologically normal breathing should be stressed as well. In this scenario, my patient has elected to proceed with an oral appliance for his sleep-related breathing disorder. As I design this device, I'll incorporate specific features to allow him to use his mouth to breathe when he's sleeping. This could be something as simple as asking the lab to incorporate venting areas for airflow. Addition of an anterior ramp will often create interarch spaces through which air could easily flow. Furthermore, some devices naturally allow for airflow. Most importantly, I'll want to include him in my design decisions and assure him that he will be able to breathe through his mouth. Dedicated mouth breathers often feel claustrophobic and may have sensitive gag reflexes. For overall treatment planning, I will also suggest a consultation with an ENT to determine the source of the congestion along with possible remedies. This may turn out to be a very important part of treatment efficacy and long-term compliance. Today, I've attempted to demonstrate the ease and simplicity of incorporating a nasal evaluation into a comprehensive examination. I believe these simple steps should take no longer than three to five minutes once the nose or other screening forms are completed. Aside from the obvious benefit of proactively taking steps to improve treatment efficacy and compliance, spending face-to-face quality time with a patient in this manner will help to establish trust and improve communication. Furthermore, outward-bound referrals to your ENT colleagues may very well lead to inward-bound referrals as well. Thank you for your attention and I hope you found this demonstration helpful.

nasal function

dental sleep medicine

nasal obstructions

mouth breathing

airway resistance