Sarah Hornsby on How to Treat Mouth Breathing at Night with Orofacial Myofunctional Therapy

When Sarah Hornsby graduated with a degree in dental hygiene, she had no idea that it would lead her to her current career. She’s a dental hygienist, but she specializes in the little-known field of orofacial myofunctional therapy, which she hadn’t even heard of during her initial training. After becoming fascinated by the topic, Hornsby went on to found two companies: Faceology, which is a virtual clinic for patients seeking this orofacial myofunctional therapy, and MyoMentor, which is to help educate other health professionals on the topic. Read on to learn what, exactly, orofacial myofunctional entails, why mouth breathing at night is such a huge and important health issue, how it all relates to tongue ties and tongue treatment, and much more.

*This is a short clip from our interview with Sarah Hornsby. Click here to watch the whole thing!*

You can also listen to the interview on The getWellBe Podcast.

What Is Orofacial Myofunctional Therapy?

First things first, let’s define what exactly it is that Hornsby does. As she explains, the term orofacial myofunctional means anything that’s related to oral muscle function, so the muscles of the jaw, mouth, and tongue, as well as any orthodontic problems. Orofacial myofunctional therapy, then, is a therapeutic approach that focuses on addressing any functional problems in this part of your body. But, she says, since “orofacial myofunctional therapy” is such a mouthful, you’ll often hear people refer to it as just “myofunctional therapy.”

“Myofunctional therapy is really easy to visualize and understand if you think about physical therapy,” Hornsby says. “So it’s basically exercises for your tongue, your lips, your mouth, your breathing, and the muscles of your head and your neck. But a lot of the therapy is focused on the tongue.” She explains that the exercises she and her colleagues prescribe to patients have four simple and specific goals:

1. For all patients to be able to breathe through their nose, rather than their mouth, all day and all night. “That is critical,” Hornsby says.
2. For all patients to have their tongue on the roof of their mouth when they’re not actively using or moving it. “I encourage everyone as they’re listening to this or watching this video, think about where your tongue is sitting right now, because it should be up in the top of your mouth,” she says. “That means your full tongue: the tip, the middle, and the back has to be touching the roof of your mouth, day and night.”
3. For all patients to have their lips together when they’re at rest/not talking or eating.
4. For all patients to be able to swallow correctly. This is always the last goal, Hornsby says, explaining that all postures must be in place before she begins to focus on the swallow. 

“Really, the goals of orofacial myofunctional therapy are very, very simple,” she says. “And in reality, you shouldn’t need a therapist to teach you these things. These are things we should be doing naturally and innately from the day we’re born. And if we’re not, then we have to start asking, what are the underlying issues? What’s causing us to mouth breathe, or what’s causing our tongue to be in the wrong place? And that’s really powerful. It’s so simple, but it lays the foundation for so many other things.” 

These simple issues, Hornsby says, can be the root cause of health problems like poor sleep (which has its own cascade of health issues), TMJ, chronic illnesses, and others. “There are so many paths you can go down once you have that foundation of breathing and tongue posture,” she says. 

How Mouth Breathing at Night Harms Your Health

One of the primary issues that Hornsby’s work targets is mouth breathing at night. It can sound so silly and small, but it’s actually at the root of a whole host of far-ranging health issues, which makes it vital to address. And the first step toward addressing it is to recognize that you’re doing it, which can be tricky on its own. 

“No one on earth wants to admit that they’re actually mouth breathing,” says Hornsby. “It takes a lot of self-awareness to be able to realize that you’re even doing it. Most patients that come to our practice, they’ve either had this discovery or someone has pointed it out to them, or they might still kind of be in denial that they’re even doing it. But it’s so important to recognize, because mouth breathing is the root cause of all sleep disordered breathing.” (Sleep disordered breathing is a wide range of sleep-related conditions related to breathing, including snoring, reduction in airflow, and sleep apnea.)

She explains that there’s a spectrum of health problems that starts off at mouth breathing, which then leads to something called upper airway resistance syndrome (UARS), which then leads to snoring, which then leads to mild sleep apnea, then moderate sleep apnea, then severe sleep apnea, “But it all starts at one end of the line, with just mouth breathing at night. So if you can correct it at just mouth breathing, it will never progress to these worse symptoms,” she says.

For people who have already noticed symptoms — like snoring, sleepiness upon waking in the morning even if you slept enough hours, restlessness at night, or others — it’s likely that they’ve already developed sleep disordered breathing. However, even at that point, if you go back to where it all started and correct the mouth breathing, you can correct these downstream symptoms, Hornsby explains. 

Mouth breathing at night can have a wide range of serious health repercussions, such as:

Changes to the brain. Recent research has shown that mouth breathing at night changes the gray matter of the brain, leading to smaller volume in multiple frontal lobe regions (the frontal lobe is the part of the brain responsible for language and executive function, among other important tasks). This was true for just noisy breathing or mouth breathing at night, before it had progressed to sleep apnea or another more serious condition. 

Higher risk of ADHD. Perhaps because of these changes to the brain, sleep disordered breathing is also associated with the symptoms of ADD and ADHD, such as trouble focusing. “The symptoms we see as ADD overlap almost 100% with the symptoms of kids who have sleep disordered breathing,” says Hornsby. “They get hyperactive because they’re exhausted. They can’t focus on anything because they’re exhausted. They’re not sleeping well because they’re not breathing well.” Research also backs up this connection. 

Higher risk of Alzheimer’s. “In adults, there’s legitimate research being done around Alzheimer’s and dementia and the long-term effects of having these breathing issues at night,” says Hornsby. “The interesting thing is we think it has to be so extreme, like severe obstructive sleep apnea, but again, we’re seeing changes in the brain even if you’re just breathing through your mouth rather than your nose at certain points during sleep.”

Hormonal disruption and stunted growth. “When you’re not getting into stage three and stage four deep sleep, that’s where it affects your body,” Hornsby explains. “And the biggest way that not getting enough deep sleep affects your body is through hormones.” This makes sense, considering that much of our hormone function — including the production, regulation, and release of hormones — happens during the deep stages of sleep. If those deep stages aren’t happening, or are getting disrupted, then hormonal disruption is almost inevitable. 

One of the ways this shows up is with regards to growth and growth hormone: Hornsby says that there’s a good deal of research linking inadequate growth hormone to mouth breathing and sleep disordered breathing in kids. “Kids who mouth breathe or don’t breathe well at night, a lot of times are smaller, thinner,” Hornsby says, adding that often after kids begin doing orofacial myofunctional therapy, they grow several inches all of a sudden because their hormones are back on track. 

Thyroid issues. Research has consistently linked hypothyroidism is frequently linked to sleep apnea and sleep disordered breathing. This is likely because of the hormone disruption described above, since thyroid function is regulated by a variety of different thyroid hormones.

What Causes Mouth Breathing?

There are a lot of different potential causes of mouth breathing, but Hornsby breaks it into three major categories: structure, function, and behavior.

Structure has to do with structural issues that could impede breathing, like a deviated septum, nasal polyps, large tonsils, or adenoids (large masses of tissue located on the back wall of the pharynx). “There can be something structurally physically wrong,” Hornsby says. 

To determine whether there’s a structural issue, she says, she does something called the “three minute lip seal test,” which involves having a client breathe through their nose for three minutes straight. She says that 97-98% of people should be able to do that, and if they can’t, then it’s likely that they have a structural issue. “These people should probably go straight to the ENT and get the structures checked out,” she says. 

When function is the issue, nasal breathing feels uncomfortable for a variety of different reasons, and you need to address it simply through practice. “It’s interesting because with nasal breathing, it actually feels really uncomfortable when you’re not used to it, and there’s a whole complex reasoning for that,” Hornsby says. “It takes three to four weeks of consistent nasal breathing to get past that, but that would be addressing the function.” 

Some examples of functional issues are asthma and allergies. “Asthma is a tricky one. It feels like you can’t take a deep breath. It doesn’t have to do with a nose issue. It feels uncomfortable, like you’re not able to get oxygen. So people with asthma tend to be mouth breathers,” says Hornsby. With allergies, which often cause chronic congestion, it’s a similar dynamic: you feel unable to take a deep breath or get enough oxygen, and so you resort to mouth breathing.

With behavior, it’s simply about breaking old habits. “We get habits. If you were a child with a lot of allergies and breathing issues, and then those allergies and breathing issues go away, you can oftentimes have the behavioral habits of mouth breathing left behind as an adult, even though you don’t have any structural or functional problems,” Hornsby says. “You just don’t think about it. It’s not something that’s at the front of your mind.” So any behavioral issues are simply addressed by breaking those habits and working on remembering to breathe consistently through your nose.

The Root Causes of Tongue Ties and Tongue Tie Treatment

Tongue ties often come up in relation to breastfeeding, but they can also affect breathing function and lead to mouth breathing. Hornsby says the conversation around tongue ties has dramatically ramped up since 2017, when a new grading system for tongue ties was introduced and people began to have more awareness about the topic. 

“Tongue ties used to be something that a lot of people didn’t understand, they denied it was even there,” Hornsby says. “Now, there’s a significant amount of research connecting tongue tie to sleep apnea, which makes sense because tongue tie can actually lead to mouth breathing. If you can’t get your tongue up to the roof of your mouth, it causes your mouth to stay open, so you mouth breathe.”

Hornsby says it’s unclear what causes tongue ties, though there are theories. Some people say that it is due to epigenetic changes that occurred in our bodies over time due to things like eating softer foods that don’t require as much chewing, fewer women breastfeeding, more pollution and toxins that could cause breathing challenges. Others say that there have always been tongue ties, but we’re just noticing and diagnosing them more now (Hornsby doesn’t give this theory a lot of weight).

Regardless of the cause, tongue ties are a structural cause of mouth breathing, and so they need to be addressed if someone wants to stop breathing through their mouth at night. Thankfully, tongue tie treatment is available to adults, and it’s pretty much the same treatment given to babies: a surgery in which the frenulum (the bottom part of the tongue connecting it to the back of the mouth) is cut in order to allow the tongue to move more freely. The surgery can be done with scissors or with a laser.

This surgery is an effective tongue tie treatment, but Hornsby emphasizes that it’s not a magic bullet, and orofacial myofunctional therapy is still necessary. “If you are going to have the tongue tie surgery, you need to do the exercises before and after,” she says.

She also emphasizes that it’s important to find the right doctor, which includes finding someone who is experienced in tongue tie surgery and who does sutures, meaning they sew up the wound rather than leaving it to heal on its own. In babies, doctors generally don’t do sutures, but for tongue tie treatment in adults, Hornsby says sutures make the healing process much easier. 

“For me, it’s a really big deal to find doctors who understand the function of the tongue and aren’t just looking at it as a one-time procedure,” Hornsby says. “I want to know that they’re doing it with the goal of proper function. So the reason in my world that you have a tongue tie surgery is so now you can get your tongue to the roof of your mouth. It’s not just to have a surgery.”

Watch our full interview with Sarah Hornsby to learn how she got into the field of orofacial myofunctional therapy, what she thinks of mouth taping, how to assess whether you’re having any disordered breathing at night that might be disrupting your sleep, the difference between mouth breathing and sleep apnea, what condition is called the “young, fit, female” version of sleep apnea, the connection between mouth breathing and gut health, and much more.

You can also listen to Adrienne’s interview with Sarah Hornsby on The getWellBe Podcast.

Do you or does someone in your life breathe through their mouth at night? Have you noticed any downstream health issues because of it? Share your experience in the comments below!

Citations:

1. Carrasco-Llatas, Marina et al. “The Role of Myofunctional Therapy in Treating Sleep-Disordered Breathing: A State-of-the-Art Review.” International journal of environmental research and public health vol. 18,14 7291. 8 Jul. 2021, doi:10.3390/ijerph18147291
2. Isaiah, A., Ernst, T., Cloak, C.C. et al. Associations between frontal lobe structure, parent-reported obstructive sleep disordered breathing and childhood behavior in the ABCD dataset. Nat Commun 12, 2205 (2021). https://doi.org/10.1038/s41467-021-22534-0
3. André C, Rehel S, Kuhn E, et al. Association of Sleep-Disordered Breathing With Alzheimer Disease Biomarkers in Community-Dwelling Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol. 2020;77(6):716–724. doi:10.1001/jamaneurol.2020.0311
4. Chiba, S et al. Nihon Jibiinkoka Gakkai kaiho vol. 101,7 (1998): 873-8. doi:10.3950/jibiinkoka.101.7_873
5. Morais-Almeida, Mario et al. “Growth and mouth breathers.” Jornal de pediatria vol. 95 Suppl 1 (2019): 66-71. doi:10.1016/j.jped.2018.11.005
6. Grunstein, R R, and C E Sullivan. “Sleep apnea and hypothyroidism: mechanisms and management.” The American journal of medicine vol. 85,6 (1988): 775-9. doi:10.1016/s0002-9343(88)80020-2

The information in this article comes from our interview with Sarah Hornsby, a myofunctional therapist, speaker, mentor, and entrepreneur. Sarah graduated from Eastern Washington University with a degree in Dental Hygiene, and is the founder of Faceology and Myomentor. You can learn more about Sarah on her website.