One of the most important questions a patient can ask me is also one of the hardest to answer:
How did I get here?
They may be sitting in my office because they snore. Perhaps they have been diagnosed with sleep apnea or upper airway resistance syndrome. They may wake with a dry mouth, grind their teeth, struggle with headaches, or feel tired no matter how long they sleep.
Others come because their teeth are crowded, their bite does not feel right, or they have worn through years of dental work from clenching. They may have had braces, teeth removed, wisdom teeth extracted, a night guard made, or a CPAP prescribed.
Each treatment may have been reasonable. Some may have been necessary.
But treatment and origin are not the same question.
We can straighten the teeth without asking why there was not enough room for them. We can protect worn teeth without asking why the body is grinding. We can support a person’s breathing at night without asking how the airway became vulnerable in the first place.
The more I have studied airway health, facial growth, nutrition, oral function, and sleep, the more I have come to believe that these problems cannot always be separated.
The teeth are not separate from the jaws.
The jaws are not separate from the tongue.
The tongue is not separate from the nose.
And none of those structures is separate from the airway.
The airway does not suddenly appear when a person reaches adulthood. It develops within a growing face, influenced by genetics, breathing, muscle function, feeding, chewing, oral posture, nasal obstruction, and many other factors.
That does not mean every person with crooked teeth will develop sleep apnea. It does not mean every person who snores has an underdeveloped jaw. Sleep-disordered breathing is complex and can involve the tonsils and adenoids, body weight, neuromuscular tone, nasal obstruction, craniofacial anatomy, and other medical conditions. But oral and facial development are important parts of that larger picture.
So perhaps the better question is not simply, “Why do I snore?”
Perhaps it is:
How did the entire breathing system develop?
What Weston Price was trying to understand
My interest in this question leads me back to the work of Dr. Weston Price.
Price was a Cleveland dentist who traveled to traditional communities around the world. He observed people living in the Arctic, Australia, the South Pacific, Africa, and other regions before industrialized Western food had fully replaced their traditional diets.
What caught his attention was not only tooth decay.
He also photographed differences in facial form, dental-arch development, tooth alignment, and the amount of room available for the teeth. He compared people eating their traditional diets with members of the same communities who had begun eating more refined flour, sugar, canned goods, and other imported foods.
His observations became the foundation of his book Nutrition and Physical Degeneration, a work that has influenced generations of biological dentists, nutrition-minded physicians, and other holistic practitioners.
Price’s work should be read for what it was: an observational field record, not a modern controlled clinical trial. He did not have sleep laboratories, cone-beam imaging, genetic testing, or the diagnostic tools we have today. His photographs cannot prove that the people he studied were free from sleep apnea.
But he asked a question that dentistry still needs to ask:
Why do some environments seem to support broader facial development and more room for the teeth, while others do not?
More recent anthropological research has also found meaningful differences in mandibular form associated with subsistence patterns. In one global analysis, the shape of the lower jaw reflected differences between agricultural and hunter-gatherer populations more strongly than neutral genetic relationships alone would predict. That does not prove that one food or one habit determines jaw size, but it supports the broader idea that the way people live and eat can influence the skeleton over time.
Genes matter. Of course they do.
But genes develop within an environment.
Modern food changed more than nutrition
When most people hear the phrase industrialized food, they think about ingredients.
They think about sugar, refined flour, artificial additives, damaged oils, preservatives, and foods that have been altered so extensively that they barely resemble what came from the ground or the animal.
Those nutritional questions are important. But there is another change we do not discuss nearly enough.
Modern food changed how much work the mouth has to do.
We have made calories remarkably easy to obtain. We can drink them. We can squeeze them from a pouch. We can eat foods that dissolve almost as soon as they enter the mouth. Grains are milled, fruits are blended, meats are mechanically softened, and snacks are engineered to require very little chewing.
Even many foods marketed as healthy are soft.
The body receives calories, but the developing mouth may receive less mechanical demand.
Bone and muscle are living tissues. They respond to use. We accept this principle throughout the rest of the body. If we load the skeleton appropriately, it adapts. If muscles are used, they strengthen. If a limb is immobilized, bone and muscle can lose strength.
The jaws are not exempt from biology.
Animal research consistently shows that reduced chewing demand can affect jaw-bone metabolism, muscle function, and aspects of maxillary and mandibular development. Human anthropology points in a similar direction, although the human evidence cannot isolate food texture from every other difference in culture, health, genetics, and environment.
This does not mean that giving a child jerky will guarantee a broad jaw or prevent sleep apnea. Biology is not that simple. It also does not mean that all cooked or processed food is harmful. Cooking has been part of human life for a very long time and can make many foods safer and more digestible.
The point is more basic:
A mouth that is developing needs appropriate work.
When nearly every meal is soft, blended, puréed, or easy to swallow, the muscles of chewing may receive less stimulation than they once did.
That is one reason I believe age-appropriate whole foods and safe opportunities to chew deserve a place in the conversation about oral development.
Development begins before the adult teeth arrive
By the time crooked adult teeth appear, the developmental story has already been unfolding for years.
The earliest chapters include nursing, swallowing, breathing, oral posture, the transition to solid foods, and eventually chewing a varied diet.
Breastfeeding is not simply a method of delivering milk. It requires coordinated activity involving the tongue, lips, cheeks, jaw, swallowing reflex, and breathing. Studies have found associations between longer breastfeeding and broader primary dental arches or lower odds of certain bite problems, including posterior crossbite. The evidence is not perfect, and feeding history is never the only factor, but it supports the idea that early oral function matters.
This is not a reason to shame mothers who could not breastfeed.
There are many reasons breastfeeding may be difficult or impossible. A baby may be premature. A mother may have medical complications. Milk supply may be limited. A child may have difficulty latching, poor coordination, restricted tongue mobility, or another feeding challenge.
Bottle-feeding does not sentence a child to poor facial development, and breastfeeding does not guarantee perfect development.
What matters is that we recognize feeding as a functional process. When it is not working well, the answer should not always be to dismiss the difficulty. Sometimes the baby and mother need help from a lactation professional, pediatrician, feeding specialist, dentist, or other qualified provider who understands oral function.
The same principle applies during weaning.
Children should not be rushed into textures they are not neurologically or physically prepared to manage. At the same time, they eventually need safe, supervised opportunities to explore food, develop chewing skills, and move beyond a diet made almost entirely of soft substances.
The goal is not to follow one rigid feeding philosophy.
The goal is healthy function.
The tongue is a quiet architect
Most people rarely think about where their tongue rests.
They notice it when they speak, swallow, taste, or accidentally bite it. The rest of the day, it seems to disappear.
But the tongue is always somewhere.
Its resting position, movement, strength, and relationship with the lips and cheeks are part of the system that surrounds the dental arches. Teeth do not erupt into an empty space. They emerge into an environment of continuous muscular forces.
When oral function is balanced, the tongue, lips, and cheeks help create a stable environment for the teeth. When the tongue rests low, pushes forward during swallowing, has restricted mobility, or cannot comfortably occupy the palate, that balance may change.
Research supports an association between tongue position or mobility and dental-arch form, although the tongue should never be treated as the sole cause of every narrow arch or crooked tooth. Genetics, tooth size, nasal obstruction, prolonged oral habits, skeletal relationships, early tooth loss, and other factors can also contribute.
This is where the anatomy becomes especially important.
The roof of the mouth is also the floor of the nose.
The upper jaw, or maxilla, helps form both the oral and nasal spaces. Development in one area cannot be entirely separated from the other.
When a child cannot breathe comfortably through the nose, the mouth may open as a compensation. The tongue may then rest lower because it cannot remain broadly against the palate while the mouth is being used as the primary breathing route.
Over time, breathing pattern, oral posture, muscle function, and facial growth may begin influencing one another. Systematic reviews have found associations between chronic mouth breathing and differences in dentofacial development, but cause and effect can move in both directions. Nasal obstruction may alter oral posture, while craniofacial anatomy may also make breathing more difficult.
That cycle is one reason simply telling a child to “close your mouth” is often not helpful.
A child who habitually mouth-breathes may not be choosing a bad habit.
The child may be compensating for an airway that does not feel open.
Common is not the same as ideal
Crowded teeth are so common that we tend to accept them as an unavoidable part of being human.
Wisdom-tooth removal is common. Braces are common. Narrow arches are common. Retainers for life are common. Children with tightly arranged baby teeth are often complimented on their beautiful smiles.
But common is not the same as ideal.
Baby teeth are smaller than the permanent teeth that will replace them. Some spacing in the primary dentition can be a favorable sign that the arches are creating room for the larger adult teeth.
A lack of spacing does not guarantee future crowding, and spacing alone cannot predict an individual child’s outcome with certainty. Longitudinal research shows that primary-tooth spacing provides useful information, but it is not a perfect forecasting tool.
Still, it is a clue.
So is a crossbite.
So is a persistently open mouth.
So is a tongue that appears unable to elevate comfortably.
So is chronic congestion.
So is a narrow, high palate.
So is snoring in a young child.
A clue is not a diagnosis. It is an invitation to look more closely.
I am part of this story myself. I did not have enough room for my wisdom teeth, so I have 28 teeth rather than the 32 that developed. Like many people, I once accepted that as simply the way my mouth was made.
Today, I ask a different question.
Why do so many people develop teeth for which their jaws have inadequate room?
Sometimes, extraction is absolutely appropriate. Sometimes keeping a tooth would create infection, damage, instability, or another serious problem. Looking for a developmental explanation does not mean criticizing every treatment performed in the past.
It means becoming more curious about the pattern.
Straight teeth are not the entire goal
Traditional orthodontics has often focused on arranging the teeth into an attractive and functional bite.
That is an important goal. People deserve teeth they can clean, use, and feel confident showing.
But when I evaluate a patient today, I also want to understand the surrounding system.
Is the upper arch narrow?
Is there room for the tongue?
Can the patient breathe comfortably through the nose?
Is there a crossbite?
Does the patient snore?
Has orthodontic treatment relapsed?
Is there evidence of clenching or grinding?
Does the patient wake rested?
These questions do not replace orthodontic diagnosis. They make it more complete.
An airway-conscious orthodontic plan should consider the teeth, jaws, tongue space, breathing pattern, growth stage, and sleep history rather than treating alignment as an isolated cosmetic problem.
That does not mean every crowded mouth needs expansion. It does not mean extraction is always wrong. It does not mean expansion by itself cures sleep apnea.
In fact, controlled evidence for rapid maxillary expansion as a stand-alone treatment for pediatric obstructive sleep apnea remains limited and inconsistent. Treatment must be based on the individual patient’s anatomy, diagnosis, age, growth, and broader medical picture.
The airway should be part of the planning.
It should not become a marketing slogan or a reason to prescribe the same appliance to everyone.
What this means for adults
Adults sometimes hear this developmental story and become discouraged.
They think, “That may help a child, but what can I do now?”
We cannot return to infancy and change how we were fed. We cannot repeat childhood growth. But understanding the pathway still matters because it helps us ask better questions.
Can you breathe comfortably through your nose during the day?
Do you wake with a dry mouth?
Has someone told you that you snore, gasp, or stop breathing?
Do you wake with headaches?
Are your teeth becoming shorter, flatter, chipped, or cracked?
Does your tongue feel crowded?
Have your teeth shifted after orthodontic treatment?
Do you feel exhausted despite spending enough time in bed?
None of these signs proves that you have sleep apnea. Clenching, fatigue, headaches, and dental wear can each have several causes.
But when multiple clues appear together, a broader evaluation may be appropriate.
That evaluation may involve a dentist, physician, sleep specialist, ear-nose-and-throat physician, orthodontist, or myofunctional therapist. The right team depends on the person and the suspected cause.
A dentist can identify risks and patterns, but a dental examination alone does not diagnose sleep apnea. When sleep-disordered breathing is suspected, referral for medical evaluation and, when appropriate, an overnight sleep study is an important part of responsible care.
What this means for parents
For parents, this information should create awareness, not fear.
A single crowded tooth does not mean a child will have sleep apnea. A few nights of snoring during a cold are not the same as chronic sleep-disordered breathing. Not every feeding difficulty is caused by a tongue tie, and not every visible tongue restriction requires surgery.
We are looking for persistent patterns.
A child who regularly sleeps with an open mouth, snores when healthy, struggles to breathe through the nose, grinds heavily, sleeps restlessly, wakes with headaches, has a crossbite, or develops a narrow dental arch deserves a closer look.
The American Academy of Pediatric Dentistry recognizes mouth breathing, frequent snoring, restless sleep, morning headaches, attention concerns, and witnessed breathing pauses among the signs that may warrant screening. In otherwise healthy children, enlarged tonsils and adenoids remain major causes of upper-airway narrowing, which is why collaboration with pediatric and ear-nose-and-throat providers is often essential.
Early observation does not always lead to early treatment.
Sometimes it leads to monitoring. Sometimes it leads to allergy care, an ENT evaluation, feeding support, myofunctional therapy, orthodontic guidance, or a sleep study.
The point is not to place every child into treatment.
The point is to stop overlooking the clues.
How did we get here?
There is no single villain.
We did not arrive at crowded teeth, narrow arches, mouth breathing, snoring, and sleep apnea because of one food, one parenting decision, one orthodontic philosophy, or one genetic change.
We arrived through a long interaction between biology and modern life.
Our food became easier to consume.
Our mouths often did less work.
Chronic nasal obstruction was sometimes accepted as normal.
Feeding problems were not always evaluated functionally.
Crowded teeth were treated as isolated dental problems.
Snoring was laughed at.
Grinding was covered with a piece of plastic.
And the mouth was often separated from the rest of the body.
I believe biological dentistry asks us to put those pieces back together.
A crowded tooth may be more than a crooked tooth.
A worn tooth may be more than a worn tooth.
A child’s open mouth may be more than a habit.
An adult’s exhaustion may be more than stress.
These are not conclusions. They are clues.
The mouth is not simply where dentistry happens. It is part of how we eat, breathe, sleep, grow, and heal.
When we begin looking at it that way, the question “How did we get here?” becomes more than a history lesson.
It becomes the beginning of better care.
Dr. John Johnson, DDS
Midwest BioHealth
The Johnson Papers