Have you ever experienced listening to a grandparent, a parent or a spouse snoring so loud you couldn’t sleep? No matter how hard you tried to ignore it, that’s all you could focus on. Then suddenly, sweet silence! You breathe a sigh of relief because they stopped! However, the only thing that stopped was their breathing. Then the silence was broken and the “sound show” resumed as they began frantically filling their lungs with air. The process was repeated over and over throughout the night. How many of us have shared these “snoring” stories in a social setting, ending in collective laughter? These “snoring” episodes are actually part of a disease process called Sleep Disordered Breathing (SDB) and it’s no laughing matter. SDB covers a broad spectrum of sleep disorders with Obstructive Sleep Apnea (OSA) being the most common. It is significant to note that OSA, along with Cancer and AIDS, are considered the most dangerous and destructive diseases on earth. 1
Originally, OSA was believed to be directly related to increased body fat, however, more recent studies confirm there are other causative factors. They include overly relaxed throat and neck muscles due to eating or drinking too closely to bedtime, nasal or pharyngeal/laryngeal blockage as well as flabby throat and oral structures, such as a large uvula or a soft floppy palate.
Exactly what is sleep apnea? SA occurs when air flow is completely stopped and diagnosed when there are five apneas (cessation of breathing during sleep) or 10 apnea-hypopnea episodes per hour of sleep. Hypopnea is defined as airflow reduced by one-half to two-thirds. 2 Apnea alone is not a problem, except when it exceeds 10 seconds in duration. There are three types of sleep apnea to acknowledge; central, obstructive, and mixed sleep apnea. Central apnea occurs when there is no respiratory effort due to brainstem immaturity of the respiratory control. This is commonly seen in premature babies and newborns. Obstructive sleep apnea is caused by airway obstruction. In young children, the obstruction is most often due to enlarged tonsils and adenoids. With a five-fold increase in childhood obesity in Canada and the United States over the last fifteen years, we see an increasing number of children with obesity-related SDB. 3,4 Mixed sleep apnea combines features of both central and obstructive causes. The Canadian Sleep Society as well as the American Sleep and Breathing Academy prove to be valuable resources relating to this topic. 5
Given the added complexity of behavioural and developmental issues that often accompany a child with SDB, our mission is to heighten the awareness for the dental professional with the purpose of earlier intervention. As co-therapists, it is important for us to have a clear understanding of our role regarding interdisciplinary management and to highlight various methodologies of treatment to broaden our scope of knowledge.
Contrary to adult SDB, pediatric SDB (OSA) often presents with behavioral symptoms that can have cascading effects in many areas of their life. These may include changes in mood, misbehavior and poor school performance. Often symptoms of SDB are confused with ADHD and as such, they are treated with medications that include stimulants, non-stimulants and antidepressants. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior or school performance issues, sleep disordered breathing should be considered.
The largest and most comprehensive study to examine the effects of sleep disordered breathing symptoms on subsequent behavior from six months to seven years was conducted in the UK. The study evaluated and followed more than 11,000 children for over six years. The combined effects of snoring, apnea and mouth-breathing on the behavior of children enrolled in the Avon Longitudinal Study of Parents and Children in the United Kingdom were examined. Parents completed questionnaires about their children’s SDB symptoms at several intervals, from six to 69 months of age. At approximately ages of four and seven years old, parents filled out the Strengths and Difficulties Questionnaire (SDQ). The SDQ rated the individual for:
- inattention/hyperactivity
- emotional symptoms (anxiety and depression)
- peer difficulties
- behavior problems (aggressiveness and rule-breaking)
- pro-social behavior (sharing, helpfulness, etc.)
The study controlled for 15 possible confounding factors, such as socioeconomic status, maternal smoking during the first trimester of pregnancy, and low birthweight as three examples. The study revealed children with sleep-disordered breathing were from 40 to 100 percent more likely to develop neurobehavioral problems by age seven, compared with children without breathing problems. The largest increase was seen in hyperactivity. There were however, significant increases across all five behavioral measures. Children whose SDB symptoms peaked early, at six or 18 months, were 40 percent and 50 percent more likely, respectively, to have behavioral problems at seven years of age compared with children who had normal breathing. Children with the worst behavioral problems had SDB symptoms that continued throughout the evaluation period and became most severe at 30 months. 6
This shines a light on the unique opportunity for dental professionals to be on the front line of discovery for numerous oral systemic diseases. Many of our patients visit the dental office more often than any other healthcare provider. Given the severity and far reaching effects, should we not consider screening for SDB on a routine basis?
The pathway to discovery begins with a clear understanding of the physical signs and symptoms of pediatric Sleep Disordered Breathing:
- Abnormal breathing during sleep
- Bruxism
- Frequent awakenings or restlessness
- Frequent nightmares
- Enuresis (bedwetting)
- Difficulty awakening
- Excessive daytime sleepiness
- Hyperactivity/behavior problems
- Daytime mouth breathing
- Poor or irregular sleep patterns
- Growth impairment
The screening process for the dental professional begins with a general observation of the patient. Mouth breathing and adenoidal facies (dull expression with open mouth) should be noted. Hyponasal voice (sounds like pinched nose when speaking) is a clue to nasal obstruction and a muffled voice suggests adenotonsillar enlargement. Secondly, the lateral facial profile should be examined for retrognathia, micrognathia or midfacial hypoplasia. These can all have an effect on the nasopharyngeal and oropharyngeal passages and are key diagnostic findings. The oral cavity should be observed for tongue and soft palate size and appearance. A large tongue along with or independent of a high/low-arched or elongated palate may reveal a predisposition to SDB. 7
Note their head posture. Blocked nasal breathing and jaw joint inflammation both result in forward head posture. Persistent forward head posture causes muscle contraction and results 96% of the time in occipital and forehead headaches. 8
Once we have established and documented our clinical findings, asking a series of questions contributes greatly to the screening process for SDB:
- Does he/she snore?
- Have you heard him/her grinding their teeth?
- Do they appear restless and/or awaken frequently at night?
- Do they have frequent nightmares?
- Do they wet their bed?
- Is it difficult to waken them in the morning?
- Are you aware of excessive sleepiness during the day?
- Are there any hyperactive or behavioural issues you are aware of?
- Would you consider the child to be a mouth breather?
In keeping with an interdisciplinary approach, it is vital to share any abnormal clinical findings with the child’s physician as soon as possible. Children are in such a rapid state of cognitive development that time is of the essence to effect change. “Any alterations of health and brain function associated with SDB could permanently alter a child’s social and economic potential, especially if the disorder is not recognized early in life or treated inadequately. It is imperative that healthcare workers actively seek out symptoms of SDB in patients and educate parents and teachers about the signs and symptoms of SDB to improve early detection and treatment for prevention of long-term morbidity”. 9
After a physical examination, a Polysomnogram (PSG-sleep study) should be prescribed by the physician to confirm the diagnosis of OSA in collaboration with the clinical suspicion, history and physical findings from the dental professional. Once the Polysomnogram is completed, severity is measured by the AHI (Apnea Hypopnea Index)
- None/Minimal: AHI < 5 per hour
- Mild: AHI > 5, < 15 per hour
- Moderate: AHI > 15, < 30 per hour
- Severe: AHI >30 per hour 10
A vast majority of cases of OSA in children are associated with adenotonsillar hypertrophy. The peak prevalence of childhood OSA is at two to eight years, which is the age when the tonsils and adenoids are the largest in relation to the underlying airway size. An endoscopy has shown the site of collapse is most often at the level of the adenoid. 11
Although research indicates variances in the success rates from tonsillectomy and adenoidectomy surgery, these procedures are often considered to be the first approach in management of pediatric SDB. 12,13
CPAP (Continuous Positive Airway Pressure) is another avenue in managing pediatric OSA. From a medical point of view, this treatment option is considered to be very successful when directions for use are followed carefully. Compliance does often present a challenge with inconsistencies in wear time, variances in care giver philosophies as well as other real life situations which can impede the success rates associated with a CPAP.
Orthodontic appliances are gaining traction as a viable option in orthopedic management of SDB in the young patient. These appliances can be used as a prevention tactic as well as secondary therapeutic management with other modalities. The appliances used most often involve expansion of the palate or anterior posturing of the mandible and tongue during sleep. The significance of early detection and treating the underlying craniofacial abnormalities in children at high risk for developing OSA, could in effect, prevent the disorder. Since maxillary constriction is a feature of chronic naso-respiratory obstruction, 14 Rapid Maxillary Expansion (RME) has the potential to play a prominent role in a prevention strategy. The quality of sleep of these children improves after RME, regardless of the severity of their respiratory obstruction. Orthodontists who perform a comprehensive head-neck examination are uniquely positioned to identify children with malocclusion that could lead to development of SDB. 15
Narrowing of the pharyngeal airway passage (PAP) and adaptations in the soft palate are common among subjects who present with a retrognathic mandible. 16,17 As a result, the space between the cervical column and the mandible decreases, leading to a posteriorly postured tongue and soft palate. This increases the chances of impaired respiratory function during the day and possibly causing SDB symptoms like snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA) syndrome. 18,19 A study was conducted to determine the effects of a twin-block appliance on the anatomy of the PAP. Thirty eight subjects (male and female) age range of eight to 14 years with skeletal Class II malocclusion associated with mandibular retrusion participated in the study. It was concluded that correction of mandibular retrognathism by functional appliances improved the dimensions of the upper airway.
“Finding Connor Deegan” is a five minute video revealing the “human” side of a child living with SDB. It illustrates the far reaching effects SDB can have on an individual’s life and how that can all change with a proper diagnosis and management strategies. We encourage you to take a few minutes to watch this video and layer your learning experience:
https://www.youtube.com/watch?v=Sk5qsmRyVcE
Regardless of the treatment option(s), the individual with SDB is considered to be at high risk for dental caries and gingival inflammation. 20 As dental professionals we know scientifically that xerostomia plays a crucial part in the formation and adherence of plaque biofilm. Consistent mouth breathing and the use of functional appliances can contribute greatly to this undesirable environment. The Philips Sonicare For Kids Power Toothbrush, with 31,000 brush strokes per minute and high amplitude, creates patented fluid dynamic action to reduce the biofilm burden. With Bluetoothconnectivity, the child can connect to an App that will help guide and coach their brushing experience in real time. Sonicare for Kids is safe and gentle for use with all appliances and removes 75% more plaque in hard-to-reach areas than a manual toothbrush in children ages seven to 10 years. 21
The collaboration of an interdisciplinary team, clinical circumstances, research and historical data all influence a customized approach to treating SDB in the young patient. As dental professionals, we want to “prevent more to treat less”. Implementing systematic screenings for Sleep Disordered Breathing should be routine and the standard of care in every dental practice.
Evidence tells us that early interventions with pediatric SDB can have a profound effect in the formative years. We all know how it feels to save a tooth. Just imagine how great it would feel to change a life!
Footnotes
1. http://www.dentistryiq.com/articles/2010/06/dentistry-s-new-frontier-the-treatment-of-obstructive-sleep-apnea.html
2. Parisi RA. Ch. 12-Respiration and Respiratory Function: Technique of Recording and Evaluation. In: Chokroverty S (ed). Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects, 2nd edition. 1999, Boston: Butterworth-Heinemann, pp. 220-221.
3. Anders TF, Eiben LA. Pediatric sleep disorders: a review of the past 10 years. J Am Acad Child Adolesc Psych 1997;36(1):9-20
4. Quality Of Life Improvement With Positive Airway Pressure Therapy For Sleep Disordered Breathing In Obese Youth
Sherri L. Katz , MDCM, FRCPC, MSc 1 , Joanna MacLean , MD, PhD 2 , Lynda Hoey , CCRP 3 , Valerie Kirk , MD 4 , Glenda Bendiak , MD 4 , Nicholas Barrowman , PhD 5 , Linda Horwood , MSc 6 , Stasia Hadjiyannakis , MD 1 , Laurent Legault , MD 6 , Bethany Foster , MD 6 , Evelyn Constantin , MD 6 , http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A1222
5. https://css-scs.ca/; americansleepandbreathingacademy.com/
6. Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years; Karen Bonuck, PhD, Katherine Freeman, DrPH Ronald D. Chervin, MD, MS, and Linzhi Xu, PhD: Pediatrics. 2012 Apr; 129(4): e857–e865. doi: 10.1542/peds.2011-1402 www.ncbi.nlm.nih.gov/pmc/articles/PMC3313633/
7. Role of oral health professional in pediatric obstructive sleep apnea: Sanjeev Kumar Verma, Sandhya Maheshwari, Naresh Kumar Sharma, K. C. Prabhat:Natl J Maxillofac Surg. 2010 Jan-Jun; 1(1): 35–40. doi: 10.4103/0975-5950.69162: PMCID: PMC3304178
8. Anterior Repositioning Appliance Therapy for TMJ Disorders: Specific Symptoms Relived and Relationship to Disc Status on MRI. CRANIO 2005; vol 23, no 2, 89-99.
9. Treatment Alternatives for Sleep-Disordered Breathing in the Pediatric Population Ann C Halbower, MD ; Brian M McGinley, MD ; Philip L Smith, MD; www.medscape.org/viewarticle/586396: Curr Opin Pulm Med CME. 2008; 14(6):551-558. © 2008 Lippincott Williams & Wilkins
10. http://healthysleep.med.harvard.edu/sleep-apnea/diagnosing-osa/understanding-results
11. Isono S, Shimada A, Utsugi M, Konno A, Nishino T. Comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. Am J Respir Crit Care Med. 1998; 157:1204–12. [PubMed]
12. http://www.sciencedirect.com/science/article/pii/S0194599809000850
13. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004500/
14. Jureyda S, Shucard DW. Obstructive sleep apnea – An overview of the disorder and its consequences. Semin Orthod. 2004;10:63–72
15. http://pubmedcentralcanada.ca/pmcc/articles/PMC4229758/
16. Kirjavainen M, Kirjavainen T. Upper airway dimensions in class II malocclusion. Effects of headgear treatment. Angle Orthod. 2007;77:1046–1053. doi: 10.2319/081406-332. [PubMed] [Cross Ref
17. Jena AK, Singh SP, Utreja AK. Sagittal mandibular development effects on the dimensions of the awake pharyngeal airway passage. Angle Orthod. 2010;80:1061–1067. doi: 10.2319/030210-125.1. [PubMed] [Cross Ref
18. Schafer ME. Upper airway obstruction and sleep disorders in children with craniofacial anomalies. Clin Plast Surg. 1982;9:555–567. [PubMed]
19. Ozbek MM, Miyamoto K, Lowe AA, Fleetham JA. Natural head posture, upper airway anatomy and obstructive sleep apnea severity in adults. Eur J Orthod. 1998;20:133–143. doi: 10.1093/ejo/20.2.133. [PubMed] [Cross Ref
20. http://jcodental-uobaghdad-edu.org/index.php/jbcd/article/viewFile/216/pdf_105
21. Milleman J, Putt M, Olson M, Master A, Jenkins W, Schmitt P, Strate J. International J Pediatric Dent 2009; 19:s1 Defenbaugh J, Schmitt P, Master A, Jenkins W, Strate J. International J Pediatric Dent 2009; 19:s1 Jenkins W, Master A, Defenbaugh J, Wei J. Philips Oral Healthcare, Snoqualmie, WA; J Dent Res 89 (spec iss B); Abstract 3696, 2010
About the Authors
Susan Woodley RDH, began practicing dental hygiene in a general dentistry setting, though the better part of her career led her to practicing in Orthodontics. Susan enjoyed many years as a part-time faculty member with a local college both lecturing and as a clinical instructor. Susan also independently presents an all-day Oral Pathology Refresher course to Dental Professionals. She developed and presents an Orthodontic course to guide the clinician in achieving clinical excellence with orthodontic procedures. She continues to be an active member of the Ontario Dental Hygienists’ Association as well as the Canadian Dental Hygienists Association.
Lee Somerville, RDH, MS, received a Master of Science in Dental Public Health from Boston University School of Graduate Dentistry. She has over 30 years in private practice experience. Lee has been an instructor at Cape Cod Community College since 1986 and has taught freshman and sophomore clinic, radiology and several didactic courses. She is a member of the American Dental Hygienists’ Association and American Dental Educator’s Association. Lee manages Professional Education for Philips North America in the Northeast. She lectures in the Northeast as well as nationally. Lee is a full-time Professional Educator with Philips North America and teaches part time at Cape Cod Community College.
