March 1, 2013
by Steven Olmos, DDS
It seems like each day we find more links to our health problems and sleep breathing disorders. Earlier this year, two studies demonstrated a five fold risk of cancer when a person has sleep apnea (interrupted breathing).1 Everyone is aware of the link of sleep breathing disorders to diabetes, cardiovascular disease, and hypertension. So, pretty much everything we die of.
It is suggested that 25% of the American population has a sleep breathing disorder (SBD) problem and should be screened.2 To date, 90% of SBD has not been diagnosed,3 and “causes damage to the brain with specific areas of grey- and white-matter loss, alteration in autonomic and motor regulation, and damage to higher cognitive functions.”4 This is true for children and adults.
On March 5, 2012, the American Academy of Pediatrics published an article entitled “Sleep Disordered Breathing in a Population-Based Cohort: Behavioral outcomes at 4 and 7 years.” The conclusion: “in this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.”
On August 27, 2012, the American Academy of Pediatrics published this article: “Diagnosis and management of childhood obstructive sleep apnea syndrome”. In this paper they establish the following recommendations: “(1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms and signs of OSAS.”
In the June 2012 addition of “Sleep and Breathing” Dr. Christian Guilleminault authored an editorial on “Orthodontics and Sleep Disordered Breathing”. He states: “Today, the field of orthodontia placed an important role in the diagnosis and treatment of sleep disordered breathing syndromes. One can see that the role of dentist and orthodontist has become very important and will continue to grow even further in the years to come.”
Doctors Pirelli and Guilleminault published their research on curing severe apnea in children with maxillary palatal expansion, in the journal “Sleep” in 2004. They took 31 children mean age of 8.7 years and a mean hypopnea index of 12.2 events per hour and brought all patients below one event per hour. Children are diagnosed with apnea if they have greater than one event per hour.
This information is esoteric until applied to real life. Dr. Melody Barron, Director of the University of Tennessee Craniofacial Pain Center, referred an 11-year-old girl to my office in San Diego recently. Anna had been diagnosed in Central California in 2009 with an RDI of 10.3, moderate to severe sleep apnea. Anna was referred to Dr. Barron from her Pediatric specialist. Dr. Schoumacher states in his letter; “The family reported that CPAP provided incomplete relief of her symptoms, and that they wanted to pursue the orthodontic approach recommended in California. In our area, only Dr. Melody Barron has the expertise to provide this service to children.” Due to the patient’s retrognathic appearance, Dr. Barron suggested orthopedic development utilizing a nonsurgical approach with orthodontics. She began this expansion process for a few months until the young girl’s family relocated to San Diego. Our office continued the orthopedic expansion of both the mandible and maxilla. Dramatic changes in the patient were noted and an interim progress PSG was ordered to evaluate the efficacy of this treatment. The results demonstrated a dramatic reduction of her condition, RDI 1.1. The patient continues in treatment until final growth and development is complete, however she is now symptom free.
Blocked nasal breathing and jaw joint inflammation both result in forward head posture. Forward head posture results in back of head and forehead headaches, due to muscle contraction. In fact the most common symptom (96% of the time) of a jaw joint disorder is occipital pain (base of skull, right side).5
The most recognizable symptom of SBD is bruxism (grinding or clenching of the teeth). The book “Bruxism Theory and Practice”, edited by Daniel A. Paesani, published by Quintessence, explains this mechanism.
“Sleep bruxism has been correlated with hyponea and increasing airway patency. More anterior and downward head postures and kyphotic neck have been found in bruxist children, with hyperflexion of the head posture.”
“The physiology in children is different. Dopamine levels in the brain increase progressively after birth to very high levels in adolescence, when they start to decrease steadily until the age of 30. This makes studies of the etiology of bruxism in children incomparable with the studies and adults. Studies in children are required because the available literature has lacked sufficient scientific rigor thus far.”
Dr. Nishcal Singh, president of the Australian Chapter of the American Academy of Craniofacial Pain, was recognized for his work on children who brux by the American Academy of Dental Sleep Medicine. He was honored with the Graduate Research Award and Excellence in Research Award for his paper entitled; “Sleep Bruxism- Related Tooth Wear as a Clinical Marker for Pediatric Sleep Disordered-Breathing.”
He found no statistically significant association between the AHI score and the dental wear score, however the RERA (Respiratory Effort Related Arousal) score itself, had a statistically significant association with the presence and severity of sleep bruxism related tooth wear.
Dentists have for many years treated jaw joint dislocation as a separate entity without the understanding of its’ relationship to SDB. Recent literature demonstrates that nocturnal bruxism is related to maintaining an airway from tongue and/or soft palate obstruction, in both adults and children.6
There is a disproportionate amount of SBD in dental patients,7 however they are simply treated for the symptoms of tooth grinding as opposed to their underlying real medical condition that dentists can treat.
Dentists are not trained in the diagnosis and treatment of SDB and therefore lack the specific training necessary for assisting medicine. An article published in the Journal of Sleep & Breathing June, 2012 describes a poll of North American dental schools that states on average only 2.97 hours of a four year dental program are devoted to this topic.OH
Steven R. Olmos, DDS, DABCP, DABDSM, DACSDD, DAAPM, FAAOP, FAACP, FICCMO, FADI, FIAO is an internationally recognized lecturer and researcher, and the founder of the TMJ & Sleep Therapy Centre’s International. Dr. Olmos is an adjunct professor at the University of Tennessee College of Dentistry, where his system of diagnosis and treatment are utilized at the school’s Craniofacial Pain Center. He is currently directing research in these fields through data collection at 14 TMJ & Sleep Therapy Centre’s and the Craniofacial Pain Center at the University of Tennessee. This effort is focused to establish protocols between dentistry and medicine for optimal treatment outcomes.
Oral Health welcomes this original article.
1. Dr. F. Javier Nieto, chair of the Department of Population Health Sciences at the University of Wisconsin School of Medicine and Public Health, presented his study at the American Thoracic Society 2012 International Conference in San Francisco on May 20th.
2. Prevalence of Symptoms and Risk of Sleep Apnea in the US Population. Results from the National Sleep Foundation Sleep in America 2005 Poll. Chest 2006;130:780-786.
3. Kapor V, Strohl KP. Under diagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath 2002:6(2):49-54.
4. Simmons M., Clark G. The potentially harmful medical consequences of untreated sleep-disordered b
reathing (The evidence supporting brain damage). JADA, Vol. 140, May 2009.
5. 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.
6. Nocturnal Bruxism As A Protective Mechanism Against Obstructive Breathing During Sleep. SLEEP, Volume 31, S A99, 2008.
7. Levendowski D., Morgan T. Prevalence of probable obstructive sleep apnea risk and severity in a population of dental patients. Sleep Breath, 2008: 12:303-309.