protocol for detection of roncopathy and osahs in …€¦ · • normal bite • anterior deep...

____________________________________________________________________________________________BottiniE.,CorominaJ.,EcharriP.,EsteveA.,FernándezMartínF.,GorinaM.,GrandiD.,LapitzL.,MarcóJ.P.,MarequeJ.,VentosaY.&VilaE.“ProtocolforDetectionofRoncopathyandOSAHSinAdultPatients”.

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PROTOCOLFORDETECTIONOFRONCOPATHYANDOSAHSINADULTPATIENTS.

Instructions

BottiniE.1,CorominaJ.2,EcharriP.1,EsteveA.3,FernándezMartínF.3,GorinaM.4,GrandiD.5,LapitzL.5,MarcóJ.P.1,MarequeJ.4,VentosaY.5yVilaE.1.

1Orthodontist;2ENT;3Physiotherapist;4Maxillofacialsurgeon,5Speechtherapist.

Introduction: This protocol consists of 12 factors which help in detecting the presence ofsnoringand/orOSAHsymptomsfromtheclinicalpointofview.Thesearephenomenawhicharesometimesdifficulttodetect,duetothefactthatmanysymptomsandsignsareproducedduringthesleep.Nevertheless,wewillfocusonsignswhichcanberelativelyeasytoobserve,althoughthepatientmightbenotawareofhisproblem.

It is very important to define the cause, and then refer the patient to a professional orprofessionals related to the origin and manifestation of the alteration: ENT, orthodontist,speechtherapist,GP,physiotherapist,maxillofacialsurgeon,etc.

InthesectionAnamnesis,wewillgiveanumericcodetoeachanswer:0for"NO",1for"YES",and 2 for "DON'T KNOW". It is not necessary to carry out this coding when filling out theprotocolform,butitwouldbeusefulinstatisticstudies.

1.Anamnesis

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Thisquestionnaire isdesignedtodeterminebasicdysfunctions,habitsandpathologieswhichmightbethecauseofthesymptomsofSleepApneaandHypoapneaSyndrome,ortobethemanifestationofsimplesnoringwithoutapnea.

Each question of anamnesis can suggest the need to refer the patient to a specialist. Forexample,thefirstfourquestionsonsnoringcanindicatethatthepatientshouldbereferredtoENT specialist to eliminate any pathologies of this field, or to a speech therapist who candetect a dysfunction of oropharyngeal musculature linked to the collapse of the upper airways.

TheanswersintheAnamnesispartshouldbecontrastedwiththeobservationsinthefollowingitems.

Thecodingisasfollows:0for"no",1for"yes",and2for"don'tknow".

2.Background

Thisitemcollectsthedataonpreviousstudiesanddiagnosiswhichcanhelpinidentifyingtheorigin of symptoms. Itwill be useful to know if the patient has ever been subjected to anyspecificsleepstudies(clinical,polysomnography,X-rays),inwhichcasewecancountonthem.

It is important toknow if there isabasicdisease,and itwillbe registered if thepatienthasalready undergone any treatment. This information will be useful both for diagnosis andtreatment.

As far as theusualmedication is concerned, somemedicines canprovokehyposialia and/orrelaxationoftheperipharyngealmusculature,andthereforeitisimportanttoputitonrecordifthepatientusesit.

Also,cardiovascularandrespiratorybackgroundcancontributetothesyndrome.

In "others"wewill add the informationonanypathologynotmentioned in theprotocol, aswell as the situations that can be relevant, for example: an accident, skeletal andmusculardiseases,autoimmunediseases,etc.,whichcaninterveneinthemanifestationofOSAH.

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Asithasalreadybeenexplained,thisprotocol'sobjectiveistodetectandreferthepatienttoacorrespondingspecialistandthereforetheaimistocollectdatawhichwillindicateusaroutetofollowindiagnosiselaborationandtheconsequentinterdisciplinarytreatment.

The coding is as follows: 1 for "yes" in the Background section (ticked box), and 0 for "no"(emptybox).

3.Profile

Threetypesoffacialprofileareconsidered,accordingtoDr.Arnett'sclassificationtonormaloraltered1,2:

• Normal,orClassI(dentalarchesarecorrectlypositioned).• Convex,orClassII(advancedmaxilla,andretractedmandible)• Concave,orClassIII(retractedmaxilla,andadvancedmandible).

Apatientwithalteredprofileshouldbereferredtoadentist.

Thecodingisasfollows:0forClassIprofile(normal),1forClassIIprofile(altered),and2forClassIII(altered).

Figure3

4.Evaluationoforopharyngealspace

Theaimofthisclassificationistoevaluateoropharyngealspaceandvisibilityofthestructures3.The patientwill be asked to open hismouth asmuch as he can, and the interior of buccalcavitywillbeobserved:tonsils,uvula,softandhardpalate.Thecorrespondingboxshouldbetickedaccordingtotheobserved.

• Class1:Allstructuresarevisible.• Class2:Upperportionoftonsils,hardandsoftpalateanduvulaarevisible.• Class3:Tonsilsareinvisible.Onlyhardandsoftpalateandtheuvulabasearevisible.• Class4:Onlyhardpalateisvisible.

ThecodingisthesameasinFriedmanClassification.


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The 3 and 4 class patients should be referred to a speech therapist specialized in orofacialmovement disorders to carry out the evaluation of the oropharyngeal musculature andfunctions.

Figure4

5.Tonguemobility

Dr.Durán4codedthetonguemobility:therearefive levelsofthetonguemobilitydependingonhowmuchthetonguetipcanbe lifted inawideopenmouth,plusa0 levelusedfor theabsoluteabsenceoftheproblemduetotheprevioussurgicalintervention:

• Level0:Surgicalintervention(liberation)ofthelingualfrenum(lingualfrenectomy).• Level1:Thetipofthetonguetouchesthepalatebehindtheupperincisorsinthewide

openmouth.• Level2:Thetipofthetonguealmosttouchesthepalatebehindtheupperincisorsin

thewideopenmouth.• Level3:Thetipofthetonguereachesthehalfdistancebetweentheupperandlower

incisorsinthewideopenmouth.• Level4:Thetipofthetongueisliftedalittlebitabovethelowerincisors.• Level5:Thetipofthetonguedoesn'treachlowerincisors(veryclosetoankyloglossia).

ThecodinginthispartisthesameasDr.Duran'slevels.

ApatientwithalteredtonguemobilityshouldbereferredtoaspeechtherapistortoanENTspecialist.

Figure5

6.Tonsils

There are five levels of tonsils size according to their relationwith the pharyngeal space inwhichtheyare,plus0levelfortheabsoluteabsenceoftheproblem4,5:

• Level0:Previoustonsillectomy.• Level1:Novisibletonsils.• Level2:Thetonsilsoccupylessthanathirdofatotalpharyngealspace(<25%).• Level3:Thetonsilsoccupythethirdpartofthepharyngealspace(25%-50%)


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• Level4:Thetonsilsoccupytwothirdsofthepharyngealspace,althoughtheystilldon'ttoucheachotherintheirmidline(50%-75%).

• Level5:TheTonsilsoccupyallpharyngealspaceandtheytoucheachother(>75%).

ThecodinginthispartisthesameasDr.Duran'slevels.

A patient with altered tonsils size (especially Levels 4 and 5) should be referred to an ENTspecialist.

Figure6

7.Adenoids

Toestablishifthereareanyalterationsofadenoidsornot,aphonetictestiscarriedout,whichconsistsofaskingapatienttopronounceawordwithnasalconsonants,forexample,"morning",firstwithandthenwithoutthepinchednose.Ifthevocaltimbresoundsthesameinbothcases,itistheindicationofapossibleadenoidhypertrophy.Ifthevocaltimbresoundsdifferent,itmeansthatthenasopharynxisn'toccupiedbyadenoidhyperthrophy.

Thebox"Endoscopy"willbetickedbyanENTspecialistincasetheresultsofendoscopyarepositive.

Thebox"ProfileX-ray"willbetickedbyanorthodontistincasetheresultsarepositive.

Bothspecialistswillputonrecordthefindingsintherespectiveboxes:"Noobstruction","Partialobstruction",or"Severeobstruction".

Thecodingofthissectionisasfollows:0fortheabsenceofobstruction,1forthepartialobstruction,and2forsevereobstruction.

Figure7


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8.Daytimebreathing

The breathing type of a patient is determined,which can be: nasal,mouth ormixed. In anorthodontic treatment, the functionalmatrix reeducation is extremely important, aswell asthe establishment of eight rules of functionalmatrix byDr. Durán6.One of the first keys tofunctionalmatrix is theestablishmentof anadequatenosebreathingpattern.Nevertheless,duetotheobstructionsorhabits,apatientsometimespresentsadifferentbreathingpatternwithopenmouth,mandibularclock-wiserotation,andairwaythroughthemouth.Inthelongterm, this breathing pattern provokes various consequences in growth and craniofacialdevelopment.

ApatientwithalteredbreathingshouldbereferredtoaENTspecialistandspeechtherapist.The coding in this section is as follows: 0 for nose breathing, 1 formixed breathing, and 2pointsformouthbreathing.

Figure8.

9.Profileocclusion

Here,thefirstmolars,caninesandincisorsrelationshipisanalyzed:

• ClassI(normal):mesiolabialcuspofthefirstuppermolaroccludesinthemesiolabialgrooveofthelowerfirstmolar.Uppercanineoccludesbetweenthedistalslopeofthelowercaninecuspandmesialslopeofthelowerfirstbicuspid.Theincisorspresentanoverjetorantero-posteriordistanceof2-3mm(upperincisorinfrontofthelowerincisor).

• ClassII/1:Theupperfirstmolar,canineandincisorsareinmoreforwardpositioninrespecttothelowerones.

• ClassII/2:Theupperfirstmolarandcanineareinamoreforwardpositioninrespecttothelowerones.Theuppercentralincisorsareinclinedtowardspalatal(palatoversion).

• ClassIII:Theupperfirstmolar,canineandincisorsareinmorebackwardpositioninrespecttothelowerones.

Apatientwithalteredocclusionshouldbereferredtoadentist.

Thecodinginthissectionisasfollows:0forClassImalocclusion,1forClassII/1malocclusion,and2forClassII/2malocclusion,and3forClassIIImalocclusion.

Figure9


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10.Frontalocclusion

Theocclusionalterationsareexaminedfromtheverticalandtransversepointofview6,7:

Verticalpointofview:

• Normalbite• Anteriordeepbite:upperincisorscovertheloweronesformorethan2-3mm.• Openbite:upperincisorscovertheloweronesforlessthan0mm.

Transversepointofview:

• Uni(orbilateral)crossbite: labialcuspofupperbicuspidsandmolarsoccludeontheinnersideofthelabialcuspoflowermolars.

Apatientwithalteredbiteshouldbereferredtoadentist.

Thecodinginthissectionisasfollows:0fornormalrelationship,1foranteriordeepbite,and2foropenbite,and3forposteriorcrossbite(uniorbilateral).

Figure10

11.Summaryofpositivesignsandsymptoms

Thesummaryofpositivedatafoundinthefirst10itemsoftheevaluationwillbewritten.

Figure11

12.Recommendedassessmentby…

At the end of the protocol, a professional or professionals to whom the patient should bereferredinordertoundergoadequateinterdisciplinarytreatmentareincluded.

Apart from the professionals indicated in continuation, it is possible that in some cases apatient should be referred to other professionals, such as: pulmonologist, neurologist,geriatrician,psychologist,etc.


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Thecodingofprofessionalstowhomthepatientshouldbereferredisasfollows:1foranENTspecialist, 2 for an orthodontist, 3 for a speech therapist, 4 for a physiotherapist, 5 for amaxillofacialsurgeon,6forotherprofessionals(specify),7formorethanoneofthem.

We'll use the same coding (in this case, 1-5) to specify which professional carried out thestudy.

Figure12

CONCLUSIONS

Thisprotocolpresentsasimpleandquickclinicalprocedurewhichallowsustocarryoutthepreliminary evaluationof a patient and to assign the specialistswho should be a part of aninterdisciplinaryteamwhichshouldparticipateinthediagnosisandthetreatment,inordertofacilitatethecorrection,tocarryouttheetiologicaltreatment,andinthiswaytoachievethemaximalpost-treatmentstabilitypossible.

Thisprotocolalsotries tounify theconceptsandnomenclatureusedbydifferentspecialists,withanaimtofacilitateandencouragetheunderstandingamongthem.Furthermore,ifthisexamination is repeated after the treatment, the treatment evolution can be defined in anobjective way, and when the work of one or various specialist who participated in thetreatmentisfinished.

REFERENCES

1. ArnettGW,BergmanRt.FacialKeystoorthodonticdiagnosisandtreatmentplanning-PartI.AmJOrthodDentofacialOrthop.1993;103:299-312.

2. ArnettGW,BergmanRt.FacialKeystoorthodonticdiagnosisandtreatmentplanning-PartII.AmJOrthodDentofacialOrthop.1993;103:395-411

3. Rabadi D, Baker AA, Al-Qudah M. Correlación entre los formatos de la orofaringe ehipofaringeyelposicionamientoenlaintubaciónendotraquealdifícil.RevBrasAnestesiol2014;64(6):433-437.

4. DuránJ.TécnicaMFS:Diagnósticodelamatrizfuncional:codificación.Ortodonciaclínica.2003;6:138-40.

5. CorominaJ,EstivillE.Tratamientodelniñoroncadory/oconapneaobstructivadelsueño:la reducciónamigdalar con laser.En:Coromina J,Estivill E.Elniño roncador.Elniñoconsíndromedeapneaobstructivadelsueño.Barcelona.2ªEd.EDIMSA2006:41

6. Durán J. Multifunction System ”MFS”. Las 8 claves de la matriz funcional. Ortodonciaclínica.2003;6:10-13.

7. Echarri P, Perez JJ. Historia clínica, examen clínico y estudio de modelos. En EcharriDiagnósticoenortodoncia:estudiomultidisciplinario.Barcelona.Nexus.2002:57-102.


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8. Ustrell J, Durán J. Diagnóstico en ortodoncia. En Ustrell J, Durán J. Ortodoncia. Primeraedición.Barcelona.Ed.UniversitatdeBarcelona.2001:61-100.

9. Olivi, H. Apnea del sueño: cuadro clínico y estudio diagnóstico (Sleep apnoea: clinicalpresentationanddiagnosticalgorithms).RevMedClinCondes2013;24(3)359-373.

10. Entrevista a la Dra. Esther Mandelbaum Gonçalves Bianchini, Boletín Oficial COLOAN,Verano2015.(www.coloan.org/adjuntos/boletines/boletin_28.pdf)

11. Echarri P, Pérez-Campoy MA, Coromina J, Grandi D. Papel do médico dentista notratamento da roncopatia e do síndrome de apneia/hipoapneia obstrutiva do sono(SAHOS).OJDentistry,abril2015;2(17):26-30.

protocol for detection of roncopathy and osahs in …€¦ · • normal bite • anterior deep...

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