PEDIATRIC SLEEP APNEA AND ITS CLOSE RELATIVE UPPER AIRWAY RESISTANCE SYNDROME Allen J Moses, DDS Assistant Professor Rush University [email protected] http://www.kidsapnea.com
Jun 26, 2015
PEDIATRIC SLEEP APNEAAND ITS CLOSE RELATIVE
UPPER AIRWAY RESISTANCE SYNDROME
Allen J Moses, DDSAssistant Professor Rush University
[email protected]://www.kidsapnea.com
OBSTRUCTIVE SLEEP APNEA IN CHILDREN IS A SERIOUS PROBLEM•ADHD•ENEURESIS•FAILURE TO THRIVE•LEARNING DISORDERS•COGNITIVE DISORDERS•BEHAVIORAL DISORDERS•DISRUPTED SLEEP•CARDIOVASCULAR PROBLEMS•HYPERTENSION
•HYPOTROPHIC FACES AND JAWS•DELAYED DEVELOPMENT OF MOTOR SKILLS•EXECUTIVE DYSFUNCTIONARE SOME OF THE COMORBID SYMPTOMS OF KIDS’ OSA
CHILDREN WITH OSA GENERATE 2.6 TIMES THE AMOUNT OF
HEALTHCARE EXPENSES AS NON-OSA CHILDREN
THESE KIDS ARE NOSE BREATHERS, SLEEPING WITH THEIR MOUTHS CLOSED. THEIR TONGUE IS IN THE ROOF OF THE MOUTH FACILITATING NORMAL GROWTH OF THE PALATE, BROAD DENTAL ARCHES STRAIGHT TEETH AND BEAUTIFUL SMILES
THESE KIDS ARE SLEEPING WITH THEIR MOUTHS OPEN. NASAL BREATHING IS OBSTRUCTED. THEY ARE MOUTH BREATHERS. THE TONGUE IS IN THE FLOOR OF THE MOUTH . THIS WILL
AFFECT THE POSITION OF THEIR DEVELOPING TEETH
THE AIRWAY COLLAPSES DURING AN APNEA EPISODE IN SLEEP
CHILDREN WHO HAVE OSA HAVE
SMALLER AND MORE OBSTRUCTED AIRWAYS THAN NON-OSA CHILDREN
THE SAME STRUCTURAL AND FUNCTIONAL PROBLEMS CREATED
BY AIRWAY OBSTRUCTIONS DURING SLEEP RESULT IN
INTERMITTENT HYPOXIAS AND HYPERCARBOXIAS IN CHILDREN
THESE SAME CONDITIONS EXIST DURING THE DAY AND AFFECT
GROWTH, POSTURE, OROFACIAL STRUCTURE AND FUNCTION,
NEUROLOGICAL AND CARDIOVASCULAR FUNCTION,
LEARNING ABILITY AND BEHAVIOR
THE GOLD STANDARD FOR DIAGNOSIS OF SLEEP DISORDERED
BREATHING IS A POLYSOMNOGRAPHIC STUDY PERFORMED AT A SLEEP LAB
4. EXAMINATION TO ASSESS THE NEED FOR ORTHODONTICS IS THE SUBJECT OF TODAY’S LECTURE
1. UARS IS MORE COMMON IN KIDS THAN OSA2. FLOW LIMITATION (UARS) CAN BE MEASURED WITH NASAL PRONGS
3. MILD CRANIOFACIAL DEVELOPMENTAL ANOMALY IS OFTEN SEEN IN KIDS WITH UARS
TODAY WE ARE DISCUSSING DIAGNOSTIC FACTORS FOUND ON EXAMINATION THAT SUGGEST CONSERVATIVE TREATMENT AND/OR PREVENTION
EARLY RECOGNITION AND PREVENTION ARE THE KEY WORDS
FAILURE TO TREAT SLEEP DISORDERED BREATHING IN
CHILDREN PUTS THEM AT RISK FOR VERY SERIOUS HEALTH
PROBLEMS LATER IN LIFE
THE EVIDENCE IS INDISPUTABLE THAT EARLY DIAGNOSIS AND
TREATMENT OF SLEEP BREATHING DISORDERS IN KIDS IS MANDATED
THERE IS STRONG EVIDENCE THAT NO ONE TREATMENT MODALITY GETS 1OO
% SUCCESSFUL RESULTS
THIS LECTURE EMPHASIZES MULTIDISCIPLINARY INVOLVEMENT
•PEDIATRICIAN•SLEEP SPECIALIST•ALLERGIST•SURGEON•NEUROLOGIST
•DENTIST•MYOFUNCTIONAL THERAPIST•PULMONOLOGIST
ADENOTONSILLECTOMY IS THE FIRST LINE TREATMENT FOR KIDS’ OSA
•CURE RATE 80% DEFINED AS DISAPPEARANCE OF SIGNS AND SYMPTOMS, NORMALIZATION OF RESPIRATORY MEASURES•20% PERSISTANCE OF OSA•T&A DOES NOT ADDRESS ACCOMPANYING SYMPTOMS SUCH AS ALLERGIES, DYSFUNCTIONAL REFLEX PATTERNS OF SWALLOWING, MOUTH BREATHING AND OROFACIAL HYPOPLASIA,
INFLAMED, ENLARGED, INFECTED TONSILS AND ADENOIDS ARE NOT THE CAUSE OF OSA
•KIDS WITH OSA AT NIGHT DO NOT OBSTRUCT DURING THE DAY•REPEATED STUDIES HAVE NOT BEEN ABLE TO RELATE THE SIZE OF T & A TO INCIDENCE OF OSA•ALL KIDS WITH ENLARGED T & A DO NOT HAVE OSA•THERE ARE KIDS WITH VERY SMALL T & A WHO HAVE OSA•THERE ARE KIDS WITH OSA WHOSE OSA PERSISTS AFTER T & A
FAILURE TO THRIVE
• DYSPHAGIA DUE TO HYPERTROPHIC TONSILS AND ADENOIDS MAY CAUSE OLFACTORY CHANGES•INCREASED RESPIRATORY EFFORT LEADS TO INCREASED METABOLIC EXPENDITURE•HORMONAL BINDING FACTORS SUCH AS INSULIN GROWTH FACTOR-1 DECREASE APPETITE
EARLY DIAGNOSIS AND TREATMENT AVERT SERIOUS MORBID AND IRREVERSIBLE
CONSEQUENCES
CARDIOVASCULAR CONSEQUENCES OF OSA
• KIDS WITH OSA ARE 3X MORE LIKELY TO HAVE HYPERTENSION
• THE ELEVATION OF B.P. IN KIDS IS PROPORTIONATE TO THE SEVERITY OF OSA
• OSA IN KIDS PREDICTS CARDIOVASCULAR RISKS LATER IN LIFE
• C-REACTIVE PROTEIN INCREASES IN KIDS WITH OSA, IS SENSITIVE MARKER FOR SYSTEMIC INFLAMMATION
• INFLAMMATION CONTRIBUTES TO ENDOTHELIAL DYSFUNCTION, VASO CONSTRICTION, AND ATHEROSCLEROSIS
BY AGE 4, 60% OF FACIAL GROWTH IS COMPLETEBY AGE 6, 80% OF FACIAL GROWTH IS COMPLETEBY AGE 11, 90% OF FACIAL GROWTH IS COMPLETE(WHEN THE SECOND MOLARS HAVE ERUPTED)
•ORTHODONTIC TX AFTER AGE 12 VIRTUALLY ASSURES RELAPSE•EARLY ORTHODONTICS ADDRESSES BREATHING, SWALLOWING AND POSTURE PROBLEMS AS WELL AS MAKING MORE BEAUTIFUL FACES
APNEIC KIDS CANNOT WAIT UNTIL AGE 12 OR OLDER TO BREATHE PROPERLY
KIDS ARE HAPPIER, SMARTER AND BETTER BEHAVED WHEN THEY SLEEP WELL
ORTHODONTICS AT AS EARLY AN AGE AS POSSIBLE TAKES ADVANTAGE OF GROWTH AND REAPS HUGE PSYCHOLOGICAL AND PHYSIOLOGICAL GAINS FOR THE CHILD
PALATAL EXPANSION•CREATES MORE SPACE IN THE MOUTH FOR THE TONGUE•FACILITATES POSITIONING THE TONGUE ANTERIORLY AND IN THE ROOF OF THE MOUTH•WIDENS THE NASAL PASSAGE & FACILITATES NASAL BREATHING (ROOF OF THE MOUTH IS THE FLOOR OF THE NOSE)•DECREASES NASAL RESISTANCE AND COLLAPSIBILITY OF THE NASAL PASSAGESKIDS WHOSE AIRWAYS DO NOT COLLAPSE AT NIGHT AS A RESULT OF PALATAL EXPANSION ALSO ENJOY IMPROVED BREATHING DURING THE DAY
TEETH AND DENTAL ALVEOLI LIE IN A POSITION OF BALANCE BETWEEN CHEEKS
LIPS AND TONGUE
• IDEALLY THE TONGUE IS IN CONTACT WITH THE ROOF OF THE MOUTH AT REST, DURING SWALLOWING AND NASAL BREATHING
• INTERVENTIONS THAT DISRUPT NASAL BREATHING CAUSE OPENING OF LIPS, LOW TONGUE POSITION, HEAD FORWARD POSTURE AND MALOCCLUSIONS
BREATHING IS A PRIMAL FUNCTION NECESSARY FOR
SURVIVALTHE RESPIRATORY CENTRAL
PATHWAY MAINTAINS THE PATENT AIRWAY AND DOMINATES REFLEX CONTROL OF THE OROPHARYNX
IT SUPERCEDES ALL OTHER REFLEXES
HUMAN BEINGS ARE OBLIGATE NASAL BREATHERS
•THE MOUTH IS MERELY A BACK-UP BREATHING ORGAN•THE NOSE IS IDEAL FOR WARMING, FILTRATION AND HUMIDIFICATION OF INHALED AIR•WITH NASAL OBSTRUCTION THE LIPS MUST PART TO ALLOW AIR TO ENTER THE MOUTH•THE TONGUE MUST LOWER ITSELF TO ALLOW AIR INTO THE PHARYNX•HYOID BONE LOWERS •MANDIBLE BECOMES RETROGNATHIC•AIRWAY NARROWS•HEAD ASSUMES A MORE FORWARD POSITION ON SPINAL COLUMN
NOSE BREATHER VS MOUTH BREATHERSNIFF TEST: CLOSE YOUR LIPS TAKE A BREATH THROUGH
YOUR NOSE AS DEP AND AS FAST AS YOU CAN
MOUTH BREATHER:NARES CONSTRICT NOSE BREATHER: NARES FLARE
THE LOW TONGUE POSITION AND MOUTH BREATHING, ONCE LEARNED BECOME THE DOMINANT REFLEX
CHILD’S HABITUAL OPEN MOUTH AND DYSPHAGIA ARE DYSFUNCTIONAL
STRUCTURAL AND POSTURAL CHANGES OCCUR AS A RESULT
THE LOWERED TONGUE POSITIONTHE NARROWING OF THE AIRWAY
AND SUBSEQUENT INCREASED COLLAPSIBILITY DURING SLEEP
PREDISPOSE TOPEDIATRIC OSA, SNORING AND
UARS
REFLEXES FROM THE OROPHARYNGEAL AREA PROTECT
THE ANTERIOR PORTAL OF THE GASTROINTESTINAL TRACT
•TRANSPORT OF FOOD AND LIQUIDS•AIRWAY FOR GASEOUS EXCHANGE BY THE LUNGS•PROTECTION OF LUNGS FROM ASPIRATION OF FOOD AND LIQUIDS
THE SWALLOW IS THE MOST COMPLEX REFLEX ACTIVITY THE HUMAN NERVOUS SYSTEM
PERFORMS
THE TEETH TOUCH IN A POSITION OF MAXIMUM OCCLUSION
THE LIPS ARE SEALED AND THE TONGUE PROPULSES THE BOLUS DISTALLY AGAINST THE PALATE
THE HEAD IS BRACED ON THE SPINAL COLUMN AND DOES NOT MOVE
KIDS HAVE COMPENSATORY REFLEXES IN ADDITION TO MOUTH BREATHING
THAT RESPOND TO OBSTRUCTED NASAL BREATHING
THEY INVOLVE ABNORMAL ADAPTIVE LIP, TONGUE AND HEAD POSTURES
THAT ALTER NORMAL FACIAL GROWTH
MOUTH BREATHER, LIPS APART AT REST, CHRONIC DRY CHAPPED LIPS
STRAINED FACIAL MUSCLES TO ATTAIN LIP CLOSURE. NOTE LOWER LIP PUSHING IN
MALOCCLUSION EVIDENT ON SMILE
LIPS PUSHED LOWER TEETH IN. TONGUE PUSHED UPPER TEETH OUT
NATURAL REST POSITION
SWALLOWING – NOTE LIPS
ANTERIOR TONGUE THRUST
REST POSITION
SWALLOWING NOTE STRAINED LIPS
THERE IS MORE TO LOOK AT IN KIDS’ BREATHING THAN PSG
•LIP POSTURE – RELATES TO SPEECH, SWALLOW AND BREATHING•SWALLOW – RELATES TO HEAD MOVEMENT AND TOOTH POSITION•HEAD POSTURE – RELATES TO SWALLOW AND BREATHING•TEETH – REFLECT LIP POSTURE, ORAL/MOUTH BREATHING, SWALLOW TONGUE POSTURE, HEAD MOVEMENT•TONGUE POSTURE - RELATES TO BREATHING, FACIAL GROWTH , AND SWALLOWING
NORMAL ORTHODONTIC FORCE
The need to retrain deleterious muscle forces is imperative to successful orthodontic treatment
SHORT FACE
• RETROGNATHIA• DEEP OVERBITE• MANDIBULAR STEP PLANE OF OCCLUSION• LATERAL TONGUE THRUST DYSPHAGIA• REDUCED VERTICAL DIMENSION IN C.O.• REDUCED TONGUE SPACE DISTAL IN C.O.
STEP PLANE OF OCCLUSION
SHORT FACENOTE:1. PROTRUDING
UPPER LIP2. RETRUDED
LOWER JAW3. DEEP LABIAL
GROOVE4. LOW TONGUE
POSITION
5. THIS KID IS A MOUTH BREATHER6. HEAD FORWARD POSTURE
LONG FACE
• OPEN MOUTH RESTING POSTURE• LOW TONGUE POSITION• MOUTH BREATHER• OBSTRUCTION INHIBITS NASAL BREATHING• USUALLY CROSSBITE• MAYBE ANTERIOR OPEN BITE• MAYBE ANTERIOR TONGUE THUST SWALLOW• MAYBE PROGNATHIC• STRAIN NOTED TO CLOSE LIPS
LONG FACENOTE:1. THE STRAINED CLOSED
LIP POSTURE2. STRAINED MENTALIS
MUSCLE3. NARROW NOSTRILS
INDICATIVE OF NASALLY OBSTRUCTED BREATHING
4. ALLERGIC SHINERS
HOW DO YOU THINK THE TEETH LOOK ?
ALL KIDS WITH MALOCCLUSION DO NOT HAVE OSAUNDERSTANDING THE RELATIONSHIPS BETWEEN
MALOCCLUSIONS AND BREATHING PROBLEMS MAY INCREASE QUALITY OF LIFE AND PREVENT OSA
SURGICAL REMOVAL OF TONSILS ADENOIDS AND OTHER
OBSTRUCTIONS TO NASAL BREATHING DOES NOT ELIMINATE
THE LEARNED COMPENSATORY REFLEXES FOR LIP, SWALLOW AND
TONGUE FUNCTION
THERE ARE TWO DISTINCT TYPES OF ORAL FUNCTION – TONIC AND PHASIC
• TONIC: LIP AND TONGUE RESTING POSTURE• PHASIC: SWALLOWING, SPEECH AND
BREATHING
PSYCHOPHYSIOLOGIC RE-EDUCATION OF TONIC FUNCTION
• GETTING THE TONGUE TO STAY IN THE ROOF OF THE MOUTH AT REST• GETTING THE LIPS TO STAY TOGETHER
AT REST WITH THE PATIENT BREATHING THROUGH THE NOSE
PSYCHOPHYSIOLOGICAL RE-EDUCATION OF PHASIC FUNCTION
• IN A CORRECT SWALLOW, TONGUE AGAINST THE ROOF OF THE MOUTH PROPULSES THE BOLUS OF FOOD BACKWARD
• TEETH TOUCH IN CENTRIC OCCLUSION DURING A SWALLOW TO BRACE THE HEAD ON THE SPINAL COLUMN
• LIPS TOUCH AND ARE UNSTRAINED• HEAD IS HELD IN A STEADY POSITION ON SPINAL
COLUMN AND DOES NOT MOVE DURING A SWALLOW
FLUTTER DVD