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Why is Mouth Breathing Bad? A Clinical Condition, Not Just A Bad Habit

Author Megan Saltsgaver covers Why is Mouth Breathing Bad? A Clinical Condition, Not Just A Bad Habit on BackTable ENT

Megan Saltsgaver • Updated Oct 23, 2024 • 75 hits

Chronic mouth breathing is a surprisingly common issue that often goes unnoticed, yet it can lead to a variety of health problems. Many people assume that as long as oxygen is coming in, the method of breathing doesn’t matter. However, nasal breathing is actually the most beneficial way to breathe. Mouth breathing, on the other hand, can become habitual from childhood, and without early intervention, it can lead to issues like improper facial development, poor posture, headaches, and disrupted sleep.

Fortunately, early orthodontic care and myofunctional therapy can help correct these habits in both children and adults, while dietary changes and, in severe cases, surgical procedures can address the structural challenges caused by chronic mouth breathing. General otolaryngologist Dr Colleen Plein provides an in-depth explanation of the benefits of nasal breathing, the often overlooked health concerns associated with chronic mouth breathing, and treatment strategies to address mouth breathing.

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

• Nasal breathing is the most beneficial mode of breathing, serving to filter, humidify, and warm the air. Nasal breathing also promotes immune function and nitric oxide production, which helps with oxygen transfer and reducing stress.

• Mouth breathing often starts in childhood and can become habitual if not addressed early. An evaluation around age four or five is recommended for chronic mouth breathers to consider orthodontic interventions like maxillary expansion.

• Chronic mouth breathing leads to issues like teeth grinding, jaw clenching, headaches, poor sleep and poor posture. Forward head posture from mouth breathing adds extra strain on the cervical spine, potentially causing neck and shoulder pain and tension headaches.

• Myofunctional therapists offer non-invasive treatments to promote oral development and retrain breathing habits. They also recommend dietary changes to encourage chewing and support proper facial growth.

Why is Mouth Breathing Bad? A Clinical Condition, Not Just A Bad Habit

Table of Contents

(1) Why is Nasal Breathing So Important?

(2) Negative Effects of Mouth Breathing

(3) When & How to Fix Mouth Breathing

Why is Nasal Breathing So Important?

We often assume that as long as we're getting oxygen, the method doesn't matter. However, few people realize that there's actually an optimal way to breathe—through the nose. Breathing through the nose with the mouth closed and the tongue resting on the roof of the mouth is the most effective way to breath.

Nasal breathing warms, humidifies, and filters the air, which is essential for protecting the immune system by keeping harmful pathogens out. It also promotes the function of cilia, tiny hair-like structures in the nose that help maintain healthy respiratory function.

Additionally, nasal breathing stimulates the production of nitric oxide in the sinuses. Nitric oxide is a vasodilator, meaning it helps widen blood vessels, which supports healthy blood pressure and reduces stress. It also enhances oxygen transfer throughout the body, as studies on athletes have shown when comparing nasal to mouth breathing. By breathing through the nose, we also naturally slow our breathing rate, improving overall efficiency

[Dr. Gopi Shah]
When you say functional nasal breathing, can you define it? Is that just not mouth breathing?

[Dr. Colleen Plein]
Essentially, yes. It's unobstructed nasal breathing with your mouth closed. The way we are meant to breathe is with our mouth closed, with our tongue sitting fully on the roof of our mouth and unobstructed airflow through the nose. Doing that has a variety of benefits that we'll talk about. That's the goal is mouth closed, breathing through your nose.

[Dr. Gopi Shah]
Mouth breathing, and this probably sounds so ignorant, especially, but it's never just habit.

[Dr. Colleen Plein]
It can become habit. It starts out, and most of the problems often start in childhood, as I'm sure you have seen in your practice, that there's some obstruction in the nose. We start out as obligate nasal breathers, everybody knows that. Our larynx is high up in the pharynx, but it descends as we get older. That's an ontogeny recapitulates phylogeny sort of thing. If you look at the animal kingdom, in animals that don't have speech, their larynx is much higher, and their tongue sits much further forward. You don't see animals with obstructive sleep apnea.

There's actually this anthropologic theory called the Great Leap Forward, which is basically how humans develop speech. What happens is the larynx descended, and the tongue came further back. We basically prioritize the pharynx over the larynx to allow us resonant speech and all the speech sounds. In doing that, the tongue came further back. Now when we lay down, we have this big muscle sitting in our mouth and our throat that can now obstruct our airway. We have the benefits of speech, but there are evolutionary downsides to that.

[Dr. Gopi Shah]
Can we, just to set the stage, talk about the importance of nasal breathing and downsides of mouth breathing? I think at a very basic level, I tend to think that breathing is breathing. You breathe through either-- maybe you have a tracheostomy, you're breathing through a hole in your neck, you're breathing through your nose, you're breathing through your mouth. If you're moving air, you're breathing. Why does it matter?

[Dr. Colleen Plein]
That's what we're taught. Oxygen is oxygen. That may be true in terms of sustaining life, but it's not necessarily true in terms of optimal function. The nose does a bunch of different things. We know that it warms and humidifies air. We know when someone has a tracheostomy, if someone has a laryngectomy, what's their biggest problem? Humidification. They don't have humidification. It filters the air that we breathe. That's very important for our immune system. The turbinates grab particulate matter. Nasal breathing is important for ciliary function inside the nose.

Part of the reason, one of the theories goes that, why do we see enlarged tonsils in kids? If they're breathing through their mouth, the tonsils, which are lymphoid organs, are getting exposed to all this air and all these particles that they shouldn't be. Now you have tonsillar hypertrophy as a secondary problem. It's not the primary problem causing the sleep apnea or those issues. It's secondary from not breathing through their nose. Our sinuses also make nitric oxide, which is produced in the mucosal lining of our sinuses. It's then put out into the nasal airway.

Nitric oxide is a vasodilator. It helps with our blood pressure. It decreases stress. It also increases the efficiency of oxygen transfer to the tissues. There's actually been studies done on elite athletes that when you change them from being nasal breathers to mouth breathers in an exercise test, their exercise capacity reduces significantly. We also know that people who breathe through their mouth actually breathe at a faster rate than people who breathe through their nose.

That actually ends up in, instead of actually having our carbon dioxide levels in our blood be slightly too low, and very subtle shifts in pH in our blood have effects on our body. There's more. I could go on, but those are, I'd say, some of the major things. The thing about it is if you look in the population, about 75% of people have some sort of issue like this. It's a problem of humanity.

[Dr. Gopi Shah]
Yes, absolutely.

Listen to the Full Podcast

Nasal vs. Mouth Breathing: Does it Matter? with Dr. Colleen Plein on the BackTable ENT Podcast)
Ep 71 Nasal vs. Mouth Breathing: Does it Matter? with Dr. Colleen Plein
00:00 / 01:04

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Negative Effects of Mouth Breathing

Chronic mouth breathers are often easy to identify, even if they don't realize mouth breathing is the root of their issues. Dr. Plein frequently sees middle-aged and younger women who come in complaining of headaches, poor sleep, teeth grinding, clenching, and sore neck and shoulders.

This combination of symptoms can be traced back to mouth breathing. Chronic mouth breathing tenses the jaw muscles, leading to clenching. Since the mouth is open for breathing, gravity pulls the head forward, creating a slouched posture. For every inch the head moves forward, an additional 10 pounds of pressure is added to the cervical spine, resulting in neck and shoulder pain. This forward posture can also cause tension headaches or migraines and can contribute to snoring. While women may not show classic symptoms of sleep apnea, it's essential to ask if they wake up multiple times during the night. For men, it’s important to ask if they frequently wake to urinate. Poor nasal breathing can lead to hypoxia, which increases levels of BNP, a hormone that signals fluid overload, triggering the need to urinate. Correcting the underlying breathing issue often alleviates many of these other symptoms.

Interestingly, most chronic mouth breathers are unaware of their condition. However, once it's brought to their attention, many patients report noticing they breathe through their mouth frequently during a follow-up visit.

[Dr. Colleen Plein]
The thing to understand is when someone is a chronic mouth breather, they usually alternate between two activities. Their mouth is open. Now, again, your muscles of mastication are engaged. Alternately, they clench too. These are people who clench their teeth during the day. You get the inflammation from the chronic clenching. The other thing that happens that we don't recognize as much is when we're mouth breathers, when our mouth is open to optimize our breathing, so it's both gravity and to optimize our breathing, what happens is our jaw comes down and our head comes forward.

You get what's called this forward head posture. If you look at someone from the side, ideally, the middle of their ear should line up with the line that goes straight through their shoulder. Forward head posture is when the head comes forward. You see all these people and I'm one of them, I have this problem, where people are always like, "Stand up straight. Why are you leaning over? Why is your posture so bad?" It's because your head is forward. For every inch your head comes forward, it adds about 10 pounds of weight to your cervical spine.

These people have chronic neck pain, chronic shoulder pain. You're like, "What do I do? No matter how many massages I get, this won't go away." The other thing that happens now is you have these like C1, C2 nerve roots that are all irritated from this. Actually, if you x-ray these people, you see they get a loss of the curvature of their cervical spine. It should have this nice soft lordosis to it, and it's actually straight when you x-ray them. The area of the spinal cord that those run through is they all run through the trigeminal nucleus. It's all the same.

I know I hate neuroanatomy. I don't like to talk about it at all. The end result is that basically, our brain starts to register this as facial pain and migraine-type symptoms. When you have these people who have chronic headaches, chronic facial pain, pressure, tension-type headaches, it's all from their head not sitting right on their shoulders. Why is their head not sitting right on their shoulders? Because they're not breathing properly. If you help these people breathe better, it's amazing how many of these headache symptoms and jaw symptoms get better.

They may need some other things. They may need some decompression therapy. There are other things you can do in the short term to get their pain better, but sending them off to the neurologist doesn't fix anything. They get put on a bunch of drugs or not recognizing their sleep problem. That's the other thing is these patients often have sleep issues and they may not have the frank obvious sleep apnea that we're used to seeing, but they're not sleeping properly. That's also contributing to their symptoms.

The one thing I would say to just bring this all together is we see these problems way more often in women than we do in men. In men, we're used to a larger guy, big neck, large tongues, sleep apnea. In women, these sleep problems and these breathing problems manifest more as pain than they do as snoring insomnolence. We think about it, it's described as the young fit female syndrome. How many of these people do we see that come in with facial pain and headaches? Often we're like, "Well, we can't help you," but we can. We definitely can. Sorry, that was a little rumbling and all over the place. I don't know if it made sense.

[Dr. Gopi Shah]
Noo.

[Dr. Ashley Agan]
No. This is great.

[Dr. Gopi Shah]
Actually, my question for you is in terms of imaging and posture, is that something, Colleen, that you're looking at on your physical exam or as soon as the patient walks in the room, you're looking at those things? Are there certain things on x-ray or MRIs that you're looking for to help you determine that, "Hey, this is maybe a posture thing that's related to mouth breathing," that helps you put it all together?

[Dr. Colleen Plein]
What I do generally is you can usually tell just from their symptoms. The way that things happen is-- Again, you have to be looking for it. Say someone comes in, middle-aged woman or even younger woman comes in and says, "I'm having headaches, or facial headaches." Then you start to ask them, "Okay, well, do you snore?" "Oh yes, I do." "Do you clench your teeth?" "Oh yes, I definitely grind my teeth." "Do you get headaches? Is your neck and shoulder sore?" "Oh yes, it's sore all the time." It's fun because they're like, "How did you know that? I didn't come in for this." You see it all the time.

I don't have to necessarily look for those things. My dental colleagues who do this, they actually take photos of people's postures and things like that. You can actually see the changes before and after treatment. I obviously don't really have time in my office to do that, but I'll ask them. I'll say, "Are people always telling you to stand up straight? That you have bad posture?" They're like, "Yes." I'm like, "Yes, it's not your fault because you're not just lazy. It's not that you just need some training. It's that your body is functionally doing this to help you breathe." It's one of those things that if you start to look for it, you see it everywhere.

I tell all my patients this is a problem of humanity that is completely under-recognized and undertreated.

[Dr. Gopi Shah]
That's a good launching-off point to talk about what your evaluation looks like. Patients come in and you're asking the right questions. I think that's probably an important thing. Do you use questionnaires? Do you use the nose score and OSC questionnaire, or do you just have your spiel of questions you go through that help guide you?

[Dr. Colleen Plein]
I don't use any questionnaires. Obviously we're sleep apnea practice, so use Epworth and StopBang, things like that. The really interesting thing too, is a lot of times you have to convince these patients that they have a nasal problem.

A lot of times they'll come in for snoring and I'm like, "Well, can you breathe through your nose?" "Yes, I breathe through my nose fine." You stick a scope in their nose, and there's just no room. You have to plant this idea in their head a little bit because, usually I'll see these patients, I'll give them some medications, they'll come back for followup, and so many of them come back and they're like, "Now that you said that, I was paying attention and you're right. I breathe through my mouth all the time."

You'll ask them, "Does your bed partner notice that when you're snoring, you sleep with your mouth open," in terms of people who come in complaining of sinusitis, or "Oh, I get a sinus infection every month." We know as ENTs that that's really unlikely that you're getting a sinus infection every single month. It happens, but it's rare. You say, "Well, when you get your-- tell me about your typical sinus infection." "Oh, I get pain here and I get pain here." I'm like, "Okay, well, does your nose feel more congested? Are you coughing? Is there green stuff coming out of your nose?" "No, no, no."

They go to their doctor and they get put on antibiotics. Starting to look for these-- I think most ENTs are pretty good at distinguishing headache from true sinusitis. What we don't want to do is when it's not true sinusitis, just push them off and say, "Well, that's not for me." Asking about their sleep quality because even if they don't snore, or don't complain of snoring, it's like, "Well, how's your sleep? Do you feel like you're resting?" They're like, "No, I wake up a couple of times a night," or in men, this is a huge thing. How many men do we see who they're like-- I say, "Do you have to get up in the middle of the night to pee?"

They're like, "Yes." They're 50 and they all say that it's their prostate. It's not their prostate. What happens, the hypoxia actually causes the heart to make more BNP which makes you actually-- it thinks that you're fluid-overloaded. Your body makes more urine and now you got to get up and go pee. There are so many people that when you treat their sleep, they don't have to get up to go to the bathroom anymore. You really shouldn't have to get up in the middle of the night to go to the bathroom, even in women. That's a big marker for me. Teeth grinding is a big thing.

I have no idea how to actually look at teeth and know if you're grinding. I'm not a dentist, but you'll ask them, "Did you grind your teeth or has your dentist ever told you that you grind your teeth?" "Oh yes." Then sometimes they'll have a mouthguard. The really important thing to know about mouthguards, about bite plates, is what they actually do is by putting something in your mouth, you now have pushed the person's tongue further back and you've actually made their sleep apnea worse. Most bite splints actually worsen sleep apnea.

People don't like to hear that when they've paid money for it, but that's why you tell them you can address both things at the same time. You can have an appliance that addresses clenching and breathing all at the same time. Again, it's this thing of, the dentist sees the teeth grinding, "Oh, we just got to protect your teeth. Let's make this thing up, but yes, your teeth will be nice, but you'll feel like crap."

When & How to Fix Mouth Breathing

Mouth breathing often begins in childhood and can become a long-term habit. According to Dr. Plein, early orthodontic intervention is key to breaking the cycle, with evaluations recommended as early as four or five years old if chronic mouth breathing is present. This age is ideal for interventions like maxillary expansion, as the cranial sutures haven’t fused yet, allowing for effective growth.

In addition to orthodontic care, myofunctional therapists can help people of all ages correct mouth breathing habits. For children, they might suggest a device like a 'Myo Munchie,' a soft mouth guard that promotes oral development through chewing. Therapists also offer techniques to encourage nasal breathing, such as keeping the mouth closed, placing the tongue on the roof of the mouth, and even suggesting dietary changes.

Dietary adjustments play an important role in encouraging proper facial development. Reducing processed foods increases the need for chewing, which helps the maxilla and mandible grow wider, allowing more room for the nasal passages. If the maxilla doesn’t expand properly, it can become highly arched, causing the nasal septum to deviate and leading to nasal valve collapse. Reducing inflammatory foods also helps by calming the nasal mucosa and improving airflow.

If chronic mouth breathing persists, more invasive treatments like turbinate reduction or septoplasty may be necessary to create a clear nasal passage

[Dr. Gopi Shah]
I apologize if this is jumping ahead, but for the child then who comes in from the age of two to six, you take out the tonsils and adenoids, or let's say it's just an adenoid problem, but they still are mouth breathing because, like you said, there might be mid-face hypoplasia. There may be retrognathia. There may be the high-arched palate. We're not always jumping to turbinates at that age. What do you do? What else should we be addressing? Because I'm like, "Oh, you're not snoring. You're not pausing. That's great. A little mouth breathing, that might just be habit." Do you grow out of that? I don't know.

[Dr. Colleen Plein]
What's so fascinating about that is I know that as a pediatric ENT, you know when you look at the studies, "Well, why do the studies show that there's a big benefit for removing the tonsils and adenoids in the short term, but in the long term, these kids still have problems?" What you're talking about is exactly the issue. We're addressing essentially the symptom, but not the problem. There's a few different things. Number one, early orthodontic intervention, super important. There are people, Kevin Boyd in Chicago and others, who really advocate for early maxillary expansion, because when you're a kid, those sutures haven't fused yet. You have a lot more wiggle room. Yes, expansion for these kids.

[Dr. Gopi Shah]
How early are we talking?

[Dr. Colleen Plein]
Basically, they'll tell you as early as they can tolerate. They really say four or five is the first time they should be having at least an evaluation if you're concerned about them having these problems because you can make such a big difference. That's number one. Usually, these people will work with people who are called myofunctional therapists. Myofunctional therapy is about promoting these behaviors of keeping the tongue on the roof of your mouth, keeping your lips sealed, strengthening the tongue, changing the diet. There are these therapists who are really trained to help in these problems.

Unfortunately, there's not a ton of them, and finding a good one is difficult, but they are out there and these interventions can make a humongous difference because we can impact the facial growth when they're younger, but the older they get, it's harder and harder to do. Once a kid is at 11 or 12, you're already behind the eight ball. The biggest thing that I advocate is actually you just got to look for these things. If you look for them, you will see them everywhere. My practice isn't-- I don't do pediatrics, but I see this in my own kids, and being able to do that is going to save so much pain and heartache and intervention later on, not to mention their quality of life overall.

[Dr. Gopi Shah]
Changing the diet in kids, does that-- basically having them chew more and eat less soft stuff?

[Dr. Colleen Plein]
Yes, within reason. At ENT, I'm still an airway doctor. I know people are super into baby-led weaning and those sorts of things. No, I don't want your child to choke on food, but age-appropriate, keeping things in their least processed form. It's difficult because the question is, you have to balance safety with functionality, but also again, minimizing processed food, which we know is good dietary advice overall.

[Dr. Gopi Shah]
Just regardless. Yes, for sure.

[Dr. Colleen Plein]
Exactly.

[Dr. Gopi Shah]
In terms of orthodontics and myofunctional therapy, we said the younger, the better, but of course, in terms of access and insurance and knowledge. It's not like this is part of our normal repertoire of workup and treatment options. My question though is, is there an age at which these things don't help, or is this something that you do for any-- whether the patient is 20, 40, 60 years old, who comes in that you say, "Okay, we're going to try myofunctional therapy." Is there a certain ages or things like that?

[Dr. Colleen Plein]
No, they work with all ages, and they have age-appropriate things. There are even age-appropriate-- just this morning I was giving my daughter this little thing. It's cool. It's called a myomunchie. Basically, it looks like a tiny little-- almost like a football mouth guard, but it's got little prongs inside of it and little things for them to do with their tongue. Basically, it's something to give them in their mouth that they're like, "Oh, I can chew on this. Oh, I can play with my tongue with this." It basically stimulates their using those muscles.

No, there's no age in which it doesn't help, but of course, and this comes back to what we were originally talking about, none of this will help you if you can't breathe through your nose. Learning to close your mouth and do all those things, well, if your nose is obstructed, you're going to naturally do that because you need to breathe. You have to look at this stuff in conjunction with getting the kids to breathe through their nose.

That's where I go back to what you were talking about about turbinates. With those kids and the sleep-distorted breathing and those sorts of things, I do start to pay attention to the nose a little bit earlier because my threshold-- and again, I don't do a ton of this, but I will get patients sent to me. I work with a dentist who does a lot of this stuff on kids and they'll say, "We've been doing everything and everything, this kid still can't breathe through their nose." I'm like, "Okay, well, we can do a turbinate reduction on them." Is it super common? No. Is there any real super downside to doing it? Not really.

Podcast Contributors

Dr. Colleen Plein discusses Nasal vs. Mouth Breathing: Does it Matter? on the BackTable 71 Podcast

Dr. Colleen Plein

Dr. Colleen Plein is a practicing otolaryngologist in Milwaukee and Chicago.

Dr. Ashley Agan discusses Nasal vs. Mouth Breathing: Does it Matter? on the BackTable 71 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Nasal vs. Mouth Breathing: Does it Matter? on the BackTable 71 Podcast

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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