PEDIATRIC SLEEP APNEA AND ITS CLOSE RELATIVE UPPER AIRWAY RESISTANCE SYNDROME Allen J Moses, DDS Assistant Professor Rush University [email protected].

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

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