Research Studies Evidence

Anatomy of SDB

OSA Risk Factors

• 134 Japanese Males• PSG and various measures• Risk Factors for Increase AHI (Apnea-Hypopnea Index)

• Age• BMI• Position of Hyoid Bone• Size of Airway (and resistance to flow)• Neck Circumference

Analysis of anatomical and functional determinants of obstructive sleep apnea.

Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.

Which is easier to breath through?

Which would you trust most?

Which would you rather have?

Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects*

•Apnea occurs due to craniofacial morphology and obesity, each with their contributions

•The single most important cephalometric variable in predicting AHI severity was the horizontal dimension of the maxilla (ie, porion vertical to supradentale [PV-A] distance).

•SDB ncreased fivefold to sevenfold in nonobese subjects and threefold in obese subjects

CHEST September 2002 vol. 122no. 3 840-851

Jerome A. Dempsey, PhD; James B. Skatrud, MD; Anthony J. Jacques, BS;Stanley J. Ewanowski, PhD; B. Tucker Woodson, MD;

Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD

Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects*

•It is the maxilla that determines the effective horizontal dimension of the pharynx, and in particular the upper pharynx.

•A constricted maxilla places the upper pharynx (pharyngeal isthmus) at increased risk of collapse with loss of muscle tone.

•According to present findings, individual differences in upper airway skeletal morphology may well explain these differences in individual susceptibility of AHI to weight gain

Chronic Mouth BreathingAnd Forward Head Position

Okuro, R.T., et.al., J Bras Pneumol. 2011;37(4):471-479

Pharyngeal Airspace

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199

Cone Beam and Airway analysis tool

•Exam for Mouthbreathing•the habitual posture of the lips•size and shape of the nostrils•control reflex of the Alar Nasalis •Glatzel mirror test•Rhinoscopy•Adenoid hypertrophy

25 Nasal breathers, 25 mouth breathers, Avg 8-9 y/o

Pharyngeal Airspace

Mouthbreathers have significantly smaller airway space.

(measurements PAS-OccL, PAS-UP, airway volume, area and minimum axial area)

Mouth breather Nasal breather

Morphology and SDB in children

“Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in6–8-year-old children.”

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

Morphology and SDB in children

•491 Finnish children 6–8 years of age• studied: BMI, occlusion, sleep survey• Looked for: Frequent snoring, apeas, open-mouth posture

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

Morphology and SDB in children

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

Risk Factor Incidence

Obesity 0

Tonsilar Hypertrophy 3.7x

Crossbite 3.3x

Convex Facial Profile 2.6x

Morphology and SDB in children

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

Morphology and SDB in children

Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

“A simple model of necessary clinicalexaminations (i.e. facial profile, dental occlusion and tonsils) is recommended to recognize children with an increased risk ofSDB.”

Narrow Airway Dynamics

• Narrow, irregular airway > •> increased shear forces >•> negative pressure pulls on soft tissue >•> tissue pulling and trauma (snoring) >•> impairment of mechanoreceptors >•> uncoordinated diaphragm and upper airway muscle contraction >• >DISORDERED BREATHING

Powell N, Guilleminault C. “Abnormal pharyngeal airflow in obstructive sleep apnea using computational fluid dynamics: Feasibility study.” Proceeding of the 9th World Congress on Sleep Apnea (Seoul, Korea) 2009

OSAS and swollen Tonsils

• The most common cause of airway collapse in children is adenotonsillar hypertrophy• There is a “significant positive relation between tonsillar enlargement and OSAS”• T-P Ratio = • T-P ratio is better predictor than visual inspection

T-P Ratio

• Compares the size of the tonsil to the size of the pharyngeal compartment• T = maximum horizontal width of tonsilar tissue• P = depth of the pharyngeal space• T/P ratio.•

Signs of OSA

frequency

• 140 children with OSA• Avg 4.5yo• AHI ~ 17• Low pO2 ~ 80%

Airway Stenosis

• Normal: A&T hypertrophy peaks at age 5-6• In OSA, hypertropy at all ages

•Airway stenosis caused by • A&T Hypertropy• Skeletal Abnormality

• Hypertrophy > Stenosis > Mouth Breathing > Skeletal abnormatility > OSA

• On the other hand, they say:•“ In addition to soft tissue factors, skeletal abnormality should be considered a cause of upper airway stenosis”

So which is it? Does a blocked airway cause poor growth, or does poor growth block the airway?

Angle Orthodontist - 1981

James McNamara

49.3% retrusive

James McNamara

v

69.6% Vertical Excess

Associations between sleep-disordered breathing symptoms

and facial and dental morphometry, assessed with screening examinations

Hyunh, et.al., AJODO, 2011, 140:762-70

SDB associated with: Swollen Tonsils and AdenoidsLong and narrow face

AllergiesFrequent Colds and Infections

Habitual Mouth Breathing

Dolicofacial shapeHigh mandibular plane angle

Narrow palateSevere crowding

Nighttime symptoms of SDB in kids

•Abnormal sleeping position•Chronic, heavy snoring•Delayed sleep onset•Difficulty breathing•Difficulty waking up in AM•Drooling•Enuresis•Frequent awakenings•Insomnia

•Mouth breathing•Nocturnal migraine•Nocturnal sweating•Periodic Limb movement•Restless sleep•Sleep talking•Sleep terror•Sleep walking•Witnessed apnea

Daytime symptoms of SDB in kids

•Morning headache•Mouthbreathing•Morning thirst•Excessive fatigue•Abnormal shyness, withdrawn, and depressive presentation

•Behavioral problems

•ADHD pattern•Aggressiveness•Irritability•Poor concentration•Learning difficulties•Memory impairment•Poor academic performance

Of the 600 orthodontic patients...

16% had long facial form86% had convex profiles (mandible set back from maxilla)

Over 50% had daytime mouth open posture

Caroline Rambaud & Christian GuilleminaultEuropean Journal of Pediatrics

DOI 10.1007/s00431-012-1727-3Pub Online: April 11, 2012

Death, nasomaxillary complex, and sleep in young children

Abrupt sleep associated death in seven children with good pre-mortem history

Findings in all 7 cases

chronic indicators of abnormal sleep

1.enlargement of upper airway soft tissues

2.a narrow, small nasomaxillary complex, with or without mandibular retroposition

“all children present a visuallyrecognizable abnormal high and

narrow hard palate”

Dental Arch Morphologyin Children with SDB

Finland, 41 children with OSA41 children with snoring41 chilren with no obstructionOrtho exam and 13 study cast measurements

K.Pirilä-Parkkinen,et.al.,European Journal of Orthodontics 31 (2009) 160–167

OSA children have...

• Significantly more:• Increased Overjet• Decreased Overbite• Narrow Maxillary Arches• Shorter Mandibular Arches

•Somewhat more: • Assymetric Arches (Cl II subdivision)• Mandibular Crowding• Anterior Open Bite

“...can be explained by long-term changes in the position of the head, mandible, and tongue in order to maintain airway adequacy during sleep.”

t factors such as nasal obstructionand mouth breathing, for example, may affect morphology

even if subjects exhibit good overall health.

If any factor interferes with their craniofacialdevelopment, the consequences could have an impact over

the course of the child’s lifetime.

Earlytreatment could alleviate symptoms easily and effectively,

which may benefit not only normal growth of the craniofacial structures but also reduce the risk of SDB in the future

The Original Report

Paper on Mac “Guilleminault OSA in children”

Sleep Apnea in Eight ChildrenChristian Guilleminault, M.D., Frederic L. Eldridge, M.D., F. Blair

Simmons, M.D., andWilliam C. Dement, M.D.

Pediatrics 1976;58;23

The Great Leap Forward

Terrence M. Davidson

The natural selection pressure for speech and languagewas so strong that the undesired consequence of OSA wascarried forward to modern man. Based on this reasoning,

obstructive sleep apnea is an anatomic illness

Department of Otolaryngology – Head and Neck Surgery, University of California, San Diego and the VA San Diego Health Care System, San Diego, CA, USAReceived 19 June 2002; received in revised form 23 October 2002; accepted 30 October 2002

Craniofacial and upper airway morphology inpediatric sleep-disordered breathing: Systematic review and meta-analysis

“There is strong support for reduced upper airway width* in children with obstructive sleep apnea.”

Vandana Katyal,et.al, AJODO, 2013 Jan;143(1):20-30

* A-P on ceph

Metanalysis of published and unpublished, moderately strong evidence

Nasal breathing helps the maxilla grow

The volume of air passing through the nose and nasopharynx is limited by its shape and diameter.

1.Continuous airflow through the nasal passage during breathing induces a constant stimulus for the lateral growth of maxilla and for lowering of the palatal vault.

Ahmet Yalcin Gungora and Hakan Turkkahramanb Eur J Dent. 2009 July; 3(3): 250–254. E-mail: aygungor@hotmail.com

Effects of Airway Problems on Maxillary Growth: A Review

Airway problems Change the Maxilla

•shorter maxillary length•more proclined maxillary incisors•thicker and longer soft palate•narrower maxillary arch • higher palatal vault.

Ahmet Yalcin Gungora and Hakan Turkkahramanb Eur J Dent. 2009 July; 3(3): 250–254. E-mail: aygungor@hotmail.com

Origins of Dental Crowding and Malocclusion

• Looked at 94 ancient Egyptian skulls • Reviewed Begg’s Attrition Hypothesis and Carlson’s Masticatory Hypothesis.• Crowding is due to lack of alveolar development.• Alveolar development depends on masticatory effort.

• Treatment should expand the arches and increase alveolar bone volume.• Best done early in life while bone if forming (ie. Before the eruption of permanent teeth.

J. Rose and R. Roblee, Compendium, 2009, 30:5, 292-300

The Masticatory Function Hypothesis

•Human skull changes from Mesolithic to Christian Era •10k year span, coinciding with transition to agricultural society and food processing technology

•Maxilla and Mandible•Moved posteriorly•Rotating underneath the forehead•Less robust•Mandibular dentition more distal, creating the “chin”

• Changes due to less chewing stress on developing jaws• (show figure 11)•Corroborated by Robert Corruccini, and Weston Price

Carlson and Van Gerven, Am J Phys Antropol, 1977,46(3), 495-506,

AnkyloglossiaAnn Otol Rhinol Laryngol Suppl. 1991 May;153:3-20.

Ankyloglossia with deviation of the epiglottis and larynx.Mukai S, Mukai C, Asaoka K.Source

Mukai Clinic and Research Institute of Biology, Kanagawa, Japan.

AbstractWe observed ankyloglossia to be usually accompanied by displacement of the epiglottis and larynx. Infants with this disease developed dyspnea and skin and hair abnormalities. In addition, they had other symptoms, such as a dark forehead, a frowning expression, a dark color around the lips, scanty eyebrows, swelling around the palpebrae, harsh respiratory sounds, hard crying, snoring, and frequent yawning. In spite of these abnormalities, they had been considered to be healthy by their pediatricians. Arterial oxygen percent saturation (SaO2) was measured while the infants were asleep, suckling, and awake. The results revealed that their SaO2 was unstable and slightly low. The symptoms and signs of this disease were very similar to those observed in victims of sudden infant death syndrome before their death. Correction of the ankyloglossia and deviation of the epiglottis and larynx resulted in great improvement of these signs as well as a stabilization and increase of SaO2.

Diagnostics

OSA QuestionnaireA Diagnostic Approach to Suspected Obstructive Sleep Apnea in ChildrenBrouilette, R, et.al. J.Pediatr 1984,105:10,10-14.

Used a questionnaire to determine:1. Negative: Normal needing no further treatment.2. Positive: Definitive OSA requiring T&A3. Possible: Symptomatic requiring further study, PSG

Topics for the 57 questions

1. Signs of sleep-related upper airway obstruction

2. Sleep Habits

3. Parentally observed problems in behavior, learning or development

4. Past History of ear, nose, or throat disease

5. Family history (breathing, SDB, T&A)

Rating: never, occasionally, frequently

Significant Factors

1. Signs of sleep-related upper airway obstruction1.Snoring2.Difficulty Breathing3.Sweating4.Restlessness5.Observed Apnea

2. Sleep Habits1.Less nighttime sleep2.More daytime sleepiness

3. Parentally observed problems in behavior, learning or development1.(none)

4. Past History of ear, nose, or throat disease1.Chronic rhinorrhea2.Recurrent middle ear infections3.Hearing problems4.Mouth breathing5.Frequent URI infections

5. Family history (breathing, SDB, T&A)1.(none)

Effects of OSA/SDB

“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.”

Sleep-Disordered Breathing in a Population-BasedCohort: Behavioral Outcomes at 4 and 7 Years

Karen Bonuck, PhD,a Katherine Freeman, DrPH,bRonald D. Chervin, MD, MS,c and Linzhi Xu, PhDa

PEDIATRICS Volume 129, Number 4, April 2012

“The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years.”

Sleep-Disordered Breathing in a Population-BasedCohort: Behavioral Outcomes at 4 and 7 Years

“...early childhood SDB effects may only become apparent years later.”

Sleep-Disordered Breathing in a Population-BasedCohort: Behavioral Outcomes at 4 and 7 Years

Karen BonuckDr Raanan Arens Dr John BentDr Sanjay Parikh (Montefiore Medical Center/Albert Einstein College of Medicine),

Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits

and Neuronal Brain Injury

•Childhood OSA is associated with •Deficits of IQ •Deficit of executive function •Possible neuronal injury in the hippocampus and frontal cortex.

•“...untreated childhood OSA could permanently alter a developing child’s cognitive potential.”

Ann C. Halbower, et.al, PLoS Medicine,August 2006 | Volume 3 | Issue 8 | e301

Snoring and Soft Tissue Dysfunction

• 52% of snoring patients have swallowing dysfunction no matter how severe the AHI.• Chronic snoring stretches and injures the tissues of the soft palate, uvula, and throat leading to more obstruction.

Dentomaxillofacial Radiology, 2003,32:311-316

Snoring in Preschoolers

Airway in OSA

Methods• Physical Exam• Nasal Exam• Upper airway collapsibility tests• Acoustic Reflection• Cephalometry• CT• MRI• Family History

Both obese, one w OSA

One in Ten 6 To 8-Year-Olds Has Sleep-Disordered Breathing, Finnish Study FindsDec. 14, 2012, Pubished in European Journal of Pediatrics.

Symptoms on spectrum from snoring to OSADaytime Symptoms• Daytime Hyperactivity• Behavior difficulties• Learning difficulties• Compromised somatic growth

Risk factors• Swollen Tonsils and Adenoids• Crossbite (Narrow Palate)• Convex facial profile

"If a child has symptoms of sleep-disordered breathing, his or her craniofacial status and dental occlusion need to be examined.

On the other hand, children with tonsillar hypertrophy, crossbite and convex facial profile should be examined to assess the quality of their sleep,"

Recognising the risk for sleep-disordered breathing at an early age allows an early intervention to prevent the progression of the disease.

the risk of 6-8 year old children for having sleep-disordered breathing is associated with certain craniofacial morphology traits, but not with excess body fat.

some of those at risk for obstructive sleep apnea syndrome as adults could be identified already in childhood

ADHD/Breastfeeding/Malocclusion/dental trauma/SDB

Understanding the relationships between breastfeeding, malocclusion, ADHD, sleep-disordered breathing and traumatic dental injuries.

Sabuncuoglu O., Med Hypotheses. 2013 Jan 7. pii: S0306-9877(12)00566-X. doi: 10.1016/j.mehy.2012.12.017. [Epub ahead of print]

We’re Dying YoungerJanuary 9, 2013

die earlier and live in poorer health

SDB linked to Maladaptive Behavior

Youth with current Sleep Disordered Breathing exhibited:1.Hyperactivity2.Attention Problems3.Aggressivity4.Lower Social Competency5.Poorer Communication6.Diminished Adaptive Skills

1.negotiate social situations2.engage in self-care 3.to meet his or her own needs4.apply skills learned in school

Perfect,M.M., etal, Sleep 2013, 36(4):517-525Risk of behavioral and adaptive functioning difficulties in youth with

previous and current sleep disordered breathing

ADHD: Real or Hype

Dr. Ned Hallowell, a child psychiatrist :”And while he still thinks that

many children with A.D.H.D. continue to go unrecognized and

untreated, he said the high rates demonstrate how the diagnosis

is being handed out too freely.”

being handed out too freely.

Use of Meds on the Rise

Sales of stimulants to treat A.D.H.D. have more than doubled to $9 billion in 2012 from $4 billion in 2007, according to the health care information company IMS Health.

Sales of stimulants$9 billion

“Criteria for the proper diagnosis of A.D.H.D... have been changed specifically to allow more adolescents and adults to qualify for a diagnosis…”

more

20% of Boys with ADHD?

Snoring and OSA in children

In recent years, it has become apparent that OSA and snoring are •not as innocuous as previously thought. •Indeed, epidemiological and pre-post treatment analyses have identified substantial morbidities that primarily affect cardiovascular and neurobehavioural systems, namely

• pulmonary hypertension, •systemic elevation of arterial blood pressure, •nocturnal enuresis, •reduced somatic growth, •behavioural problems that resemble attention deficit-hyperactivity disorder, •learning and cognitive deficits.

•These problems are associated with marked increases in healthcare-related costs. More importantly, if timely diagnosis and intervention are not implemented, some of these morbid complications may not be completely reversible, leading to long-lasting residual consequences.

Snoring and obstructive sleep apnoea in children: Why should we treat?David Gozal , Louise M. O'BriePaediatric Respiratory ReviewsVolume 5, Supplement 1, January 2004, Pages S371-S376

Disk Displacement and Mandibular Growth

Temporomandibular joint disk displacement and subsequent adverse mandibular growth Fredrik Bryndahl

UMEÅ UNIVERSITY ODONTOLOGICAL DISSERTATIONS New series No. 103, ISSN 0345-7532, ISBN 978-91-7264-523-3

bilateral nonreducing TMJ disk displacement caused bilateral impairment of mandibular growth (19%),

resulting in a retrognathic growth pattern.

It caused destructive changes in the condylar cartilage

In rabbits, the disc was artificially pulled out of place, Creating bilateral disc derangement without reduction...

Implications for treatment

“...early treatment implying normalization of disk position should be considered, and in doing this

the need for future corrective therapy might be reduced.”

If the disc reduces, then pull-forward treatment that reduces the disc can be beneficial to future growth.

But if the disc does not reduce, then pull-forward treatment may aggravate the joint and lead to condylar degeneration.

Therefore, must study the joint before treatment

Occlusal Wear

• Occlusal Wear (attrition) is a NORMAL part of physiology in ancient and indigenous skulls• There is less wear now (90’s) than even the recent past (1950’s)• Less wear associated with

• Processed, easy to chew, food• Increased open mouth posture• Increase incidence of malocclusion

Tooth Wear in the Mixed Dentition: A Comparative Studybetween Children Born in the 1950s and the 1990s

Andrea Marinellia, et.al., Angle Orthodontist, Vol 75, No 3, 2005, 340-343.

studies19,20 on the secular trend of malocclusions in recent years advocated that the change in dietary habits that occurred in the past decades appears to be linked to the increased prevalence of occlusal disorders. The decrease in masticatory activity as a consequence of the increased use of processed food could also be responsible of inadequate wear of deciduous teeth along with underdeveloped jaws. Dental interferences and forced guidance of mandible to an incorrect position in both the sagittal or transverse planes result from lack of physiological changes in the dental arches.22,23 On the contrary, the use of hard and fibrous foods is associated with a greater diameter of the dental arches, with an increased wear of occlusal surfaces,13 and with a smaller probability of occurrence of anomalous occlusal patterns.Mouth breathing, as a consequence of the increased prevalence of allergies,28 has also been reported as a significant cause for the amplified prevalence of malocclusions in the past years.19

Treatment SDB

J Oral Maxillofac Surg. 2011 Nov;69(11):e395-400. Epub 2011 Jul 27

Effect of mono- and bimaxillary advancement on pharyngeal airway volume: cone-beam computed

tomography evaluation.

Hernández-Alfaro F, Guijarro-Martínez R, Mareque-Bueno J.

•A statistically significant increase in the pharyngeal airway volume occurred systematically. •The average percentage of increase was:• 69.8% with MMA• 78.3% with Mandibular Advancement • 37.7% with Maxillary Advancement

Mandibular Protrusion Device helps Pediatric OSA

Randomized Controlled Study of an Oral Jaw-Positioning Appliance for the Treatment of Obstructive Sleep Apnea in Children with

MalocclusionMARIA P. VILLA, EDOARDO BERNKOPF, JACOPO PAGANI, VANNA BROIA, MARILISA MONTESANO,

and ROBERTO RONCHETTI1 American Journal of Respiratory and Critical Care Medicine, Vol. 165, No. 1(2002), pp. 123-127.

Do this…..

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line

Angle Orthodontist, Vol 00, No 0, 0000 (pre-publication 2012)

“the dimension of the velopharynx, glossopharynx, and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolars…” “Any factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon {the pharynx}.”

“the more the incisors were retracted, the more the pharyngeal airway was reduced.”

OSA TX and Brain Function

treatment of OSA in children normalizes brain metabolites in portions of the neuronal network responsible for attention and executive function," concluded Halbower. "We speculate that if OSA is treated earlier, there may be a more brisk improvement in the hippocampus, a relay station for executive function, learning, and memory."

Ann Halbower, MD, associate professor at the Children's Hospital Sleep Center and University of Colorado Denver

presented at the ATS 2012 International Conference in San Francisco

•11 kids with OSA•Treated with T&A, CPAP, and nasal treatments

•children with OSA before treatment• significantly decreased N-acetyl aspartate to choline ratios (NAA/

Cho) in the left hippocampus and left frontal cortex, •along with significant decreases in the executive functions of verbal memory and attention.

•

Trainer

“...POT appliance showed a positive influence on the masticatory and perioral musculature.”

Influence of Pre-Orthodontic Trainer treatment on the perioral and masticatory muscles in patients with Class II division 1 malocclusion

1. Tancan Uysal*,**, Ahmet Yagci*, Sadik Kara*** and Sukru Okkesim***

European Journal of Orthodontics ,2011, Volume 34, Issue 1 Pp. 96-101

Oral Myofunctional Therapy Applied on Two Cases ofSevere Obstructive Sleep Apnea Syndrome

“The results show an: •extreme regression of the syndrome, •a decrease in the apnea/hipopnea index,•the diurnal sleepiness symptoms and snoring, •as well as an improvement in oxygen saturation”

Danielle Barreto e Silva Pitta, et.al, Intl. Arch. Otorhinolaryngol.,São Paulo, v.11, n.3, p. 350-354, 2007.

“...the maxilla continued to grow forward after treatment, which was maintained in the long-term observation.”

Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway

•25 x 11 year olds•Reverse Pull HG, 350 g, 14h/d for 6 months• Follow-up 4 years post-treatment• 2D analysis only (cephs)

Emine Kaygısız et.al., Angel Orthodontist, Volume 79, Issue 4 (July 2009)

“improved the nasopharyngeal and oropharyngeal airway dimensions initially, …. was maintained at long-term follow-up.”

American Academy of PediatricsSUBCOMMITTEE ON

OBSTRUCTIVE SLEEP APNEA SYNDROME

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

-Clinical Guidelines--Technical Report-

http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672

Carole L. Marcus, MBBCh, Lee J. Brooks, MD, Sally Davidson Ward, MD,Kari A. Draper, MD, David Gozal, MD, Ann C. Halbower, MD, Jacqueline Jones, MD, Christopher Lehmann, MD, Michael S. Schechter, MD, MPH,Stephen Sheldon, MD, Richard N. Shiffman, MD, MCIS, and Karen Spruyt, PhD

Stephen Sheldon, DO (Sleep Medicine, GeneralPediatrician; Liaison, National Sleep Foundation;No financial conflicts; Affiliated with Children’s Memorial Hosp, Chicago; Published research related to OSAS)

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

•Review of 350 relevant articles•The prevalence of OSAS ranged from 0% to 5.7%,•obesity being an independent risk factor. •OSAS was associated with

• Cardiovascular•Growth deficits•Neurobehavioral abnormalities•Possibly inflammation.

•Most diagnostic screening tests had low sensitivity and specificity. •Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities.

History•Frequent snoring (≥3 nights/wk)•Labored breathing during sleep•Gasps/snorting noises/observed episodes of apnea•Sleep enuresis (especially secondary enuresis)a•Sleeping in a seated position or with the neck hyperextended•Cyanosis•Headaches on awakening•Daytime sleepiness•Attention-deficit/hyperactivity disorder•Learning problems

Physical examination•Underweight or overweight•Tonsillar hypertrophy•Adenoidal facies•Micrognathia/retrognathia•High-arched palate•Failure to thrive•Hypertension

Symptoms and Signs of OSAS

The 8 KEY ACTION STATEMENTS

1.Screening for OSAS•As part of routine health maintenance visits, clinicians should inquire whether the child or adolescent snores

2. Referral and Testing•Regular snoring or S&S should be referred for PSG, ENT eval, SM eval, or other tests (video, home study)•sensitivity and specificity of the history and physical examination are poor

3. Tonsiloadenectomy• Has OSAS AND hypertrophy, the T&A is “first line of treatment.”

4.High Risk T&A•Monitor Postoperatively

5.Revaluation•Further treatment is necessary in approx 21% (in obese, 73%)

6.CPAP•If T&A can’t be done or didn’t work•Compliance is a problem

7.Weight Loss•If needed, with everything else

8.Nasal Sprays•intranasal corticosteroids for children with mild OSAS (pre- or post T&A)

Rapid Maxillary Expansion

Two case studies without controls (level IV)•Study 1

•31 patients•4 months after RME, all patients had normalized AHI•Pirelli P, Saponara M, Guilleminault C., Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761–766

• Study 2•14 eligible sleep center patients•a significant improvement in signs and symptoms of OSAS as well as polysomnographic parameters•Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128–134

Data were insufficient to recommend rapid maxillary expansion.

Rapid Maxillary Expansion

Conclusions•“an orthodontic technique that holds promise as an alternative treatment of OSAS in children”•“maxillary expansion may be effective in specially selected patients”•“data are insufficient to recommend its use at this time.”

Increasing the Airway

• 53 patients, avg 12 years old• Biobloc treatment for avg 20 months• Posterior airway measured on ceph

Cranio April 2007, (25:2)

•31% Increase in nasopharynx area•23% Increase in oropharynx area•9% Increase in hypopharynx area

Oral Myology helps OSAEffects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome

1. Kátia C. Guimarães1, Luciano F. Drager1, Pedro R. Genta1,Bianca F. Marcondes1 and Geraldo Lorenzi-Filho1

Am. J. Respir. Crit. Care Med.May 15, 2009 vol. 179 no. 10962-966

•N = 30 subjects with moderate OSA, •BMI = 30 avg, Waist = 40 inch avg

• 15 did exercises involving the tongue, soft palate, and lateral pharyngeal wall.

• 30 minutes/day for 3 months• 15 did sham exercises

•Decreased snoring (freq and intensity)

•Decreased sleepiness (Epworth)

•Improved sleep quality•Decreased AHI (from 22 to 13 on average)

•No change in weight but neck size decreased

Include Ortho in SDB Tx

“...orthodontic therapy {maxillary expansion and mandibular advancement} should be encouraged in pediatric OSAS…

...an early approach may permanently modify nasal breathing and respiration, thereby preventing obstruction of the upper

airway.”

Sleep Breath 2012, 16:971-976

Literature review

Ortho and Ped OSA

Report of two casesCase 1• 8yo girl• T&A did not relieve OSA• RME and Frankel II gave total relief.• No further treatment needed

Case 2• 6.5yo boy w muscular dystrophy• Long face, mouthbreathing• FR II reduced all apneas, though some hypopneas remained

Rose and Schessel, JOrofacial Orthopedics, 2006,67:58-67

Ortho and Ped OSA

“Orthodontic therapeutic measures should be considered as a causal treatment option in

children with OSAS and craniofacial anomalies restricting

the upper airway”

Ortho and Ped OSAChad M. Ruoff & Christian Guilleminault

Sleep Breath, 2011, pub online, May 11

Surgical treatment of the maxilla and mandible offers a more definitive therapy for OSA...but has risks.

The “environment plays an important role in the development of SDB. Therefore, manipulation of environmental actors may decrease the development of OSA. There is a need to better define these environmental factors and predict those at risk for the development of OSA so that orthodontists and dentists can both treat and prevent OSA.”

Ortho and Ped OSAChad M. Ruoff & Christian Guilleminault

Sleep Breath, 2011, pub online, May 11

“Although dentists and orthodontia recognize the importance of evaluating and treating OSA, they have yet to realize how well-positioned they are for the prevention of sleep-disordered breathing (SDB).”

Ortho and Ped OSA

1. Clearing Nasopharyngeal Airway1.Reduction of Tonsillar Enlargement

1. Anti-leukotrienes (Singulair)2. Reduction of micro-trauma from mouth-breathing3. Surgical removal

2. Nasal Cleaning3. Nasal Surgery

2. Palatal Expansion and Advancement1.Orthodontically2. Distraction Osteogenesis3. Orthognathic Surgery

3. Muscle Training1. Oral myofuntional therapy

Chad M. Ruoff & Christian GuilleminaultSleep Breath, 2011, pub online, May 11

Mandibular Advancement

Sleep Breath (2012) 16:971–976

“Orthodontic therapy should beencouraged in pediatric OSAS,

and an early approach maypermanently modify nasal breathing and respiration, thereby preventing obstruction of the upper airway.”

Yesss!!!

Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood

“Consequently the most important missing diagnosis is the airway.

Nevertheless, breathing is the most important action for human beings to live; we forgot the airway to make

a diagnosis of the orthodontic patients.”

Sleep and BreathingPublished online: 17 November 2005©

10.1007/s11325-005-0028-8Review

Makoto Kikuchi

Comparison case

Older sister: Extract two upper premolars. Airway 14 to 10mmYounger sister: Non-extraction. Airway from 14-17mm

Comparison case

The result of the treatment looks almost the same from the appearance; however, there were big

differences between the sisters inside the face that was the most important structure for human beings:

the size of the airway.

3yo Tx with Frankel

•3 yo boy, normal occlusion in primary dentition•Significant OSA due to collapse of sides epiglottis (aryepiglottal folds)•Significant desaturations...80%•No Adenotonsilar hypertrophy•Treated with Frankel II appliance

• Mandibular advancement•Nighttime wear only

•Significant improvements in•Snoring•Apnea•Arousals•Only occasional desats of 88%•Daytime behavior

Case Report: Schessel,et.al. Respiration 2008:76,112-116

Trainers

20 cases, Class II div 1, avg 9yo

After 13 months trainer wear

Significant reduction of overjet due to dento-alveolar compensation

Angle Ortho, 2004, 74:605-609

Trainers

i

JAPANESE JOURNAL OF CLINICAL DENTISTRY FOR CHILDREN 2009 APRIL (Vol.14 No.4)

Phase I doesn’t matter

• Prospective Randomized Control Trial• Class II severe overjet (>7)mm• Early treatment with Headgear or Bionator• Improvements show in Phase I• Improvements disappeared after braces put on

Am J Orthod Dentofacial Orthop. 2004 Jun;125(6):657-67.Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Tulloch JF, Proffit WR, Phillips C.

Setback at your Peril

Bilateral SSRO: “the pharyngeal airway was constricted significantly at the oropharyngeal and hypopharyngeal levels at both the short-term and the long-term follow-ups”

Lefort I plus SSRO: “bimaxillary surgery rather than only mandibular setback surgery is preferable to correct a Class III deformity to prevent narrowing of the pharyngeal airway space

American Journal of Orthodontics & Dentofacial OrthopedicsVolume 131, Issue 3 , Pages 372-377, March 2007

Effects of bimaxillary surgery and mandibular setback surgery on pharyngeal airway measurements in patients with Class III skeletal deformities

• Fengshan Chen, Kazuto Terada, Yongmei Hua, Isao Saito

Best time to modify the palate

Three-dimensional longitudinal evaluation of palatal vault changes ingrowing subjectsThe Angle Orthodontist: July 2012, Vol. 82, No. 4, pp. 632-636.Jasmina Primozˇicˇ a; Giuseppe Perinettib; Stephen Richmondc; Maja Ovsenikdhttp://www.angle.org/doi/pdf/10.2319/070111-426.1

CONCLUSIONS

1. Palatal growth modifications were detected duringprimary dentition through early and intermediatemixed dentition stages.

2. Orthopedic treatment in the upper jaw should beperformed during this period to enhance treatmentefficiency.

Early expansion helps palatal volume

II. Three-dimensional assessment of palatal change in a controlled studyof unilateral posterior crossbite correction in the primary dentition.

Primozic J. Baccetti T. Franchi L. Richmond S. Farcnik F. Ovsenik M.European Journal of Orthodontics. 35(2):199-204, 2013 Apr.[Journal Article. Research Support, Non-U.S. Gov't]UI: 23524586Authors Full NamePrimozic, Jasmina. Baccetti, Tiziano. Franchi, Lorenzo. Richmond,Stephen. Farcnik, Franc. Ovsenik, Maja.

ABSTRACT The aim of this study was to quantify the palatal change in threegroups of children: children with a unilateral posterior crossbite(TCB) who were treated, children with untreated unilateral posteriorcrossbite (UCB), and children without a crossbite (NCB). Study castsof 60 Caucasian children in the primary dentition (20 TCB, 20 UCB, and20 NCB), aged 5.4 +/- 0.7 years, were collected at baseline (T1) andat 1-year follow-up (T2). Both TCB and UCB groups had unilateralposterior crossbite and midline deviation. The TCB group was treatedusing a cemented acrylic splint expander in the upper arch. The studycasts were scanned using a laser scanner and palatal surface area,palatal volume, and symmetry of the palatal vault were evaluated andcompared between the three groups. At T1, the palatal volume of TCB(2698 mm(3)) and UCB (2585 mm(3)) was significantly smaller than thatof NCB (3006 mm(3); P < 0.05, analysis of variance test). Aftertreatment, the palatal volume of the TCB group (3087 mm(3)) increasedand did not differ from the NCB group (3208 mm(3)), whereas the UCB(2644 mm(3)) had a significantly smaller palatal volume than the NCBor TCB groups (P < 0.05). The increase of palatal volume in the TCBgroup (389 mm(3)) was significantly greater than in the UCB (59 mm(3))and NCB (202 mm(3)) groups. The symmetry of the palatal vault wasgreater than 90 per cent in all three groups at T1 and at T2.Treatment of unilateral posterior crossbite in the primary dentitionhas a significant effect, particularly on the palatal volume increase.

Boyd comment-

The primary causal component of posterior crossbite in kids (with LTS) is compensatory functional shift of the mandible in response to unbalanced occlusion due to moderate/severe maxillary (transverse) skeletal/palatal constriction; however, most children with moderate/severe maxillary (transverse) skeletal/palatal constriction do not actually go into a compensatory functional shift of the mandible because they can adequately intercuspate with the mandibular dentition. It's a good thing that most pedos and RO's no longer dispute that posterior crossbites are best treated in kids with LTS....so why neglect to treat, those kids who have equal or more maxillary constriction merely because they don't exhibit posterior crossbite...makes no sense!

Buteyko

Control Pause

1975, researchers Stanley et al noted that breath holding was a simple test to determine respiratory chemosensitivity and concluded that "the breath hold time/partial pressure of carbon dioxide relationship provides a useful index of respiratory chemosensitivity which is not influenced by airways obstruction."

Evaluation of breath holding in hypercapnia as a simple clinical test of respiratory chemosensitivity. Stanley,N.N.,Cunningham,E.L.,Altose,M.D.,Kelsen,S.G.,Levinson,R.S.,and Cherniack,N.S.(1975).Thorax,30,337-343.

Control Pause

Nishino acknowledged breath holding as one of the most powerful methods to induce the sensation of breathlessness, and the breath hold test "gives us much information on the onset and endurance of dyspnea (breathlessness)." The paper noted two different breath hold tests as providing useful feedback on breathlessness. The first breath hold test is the length of time until the first urges to breathe. This easy breath hold provides information of how soon first sensations of breathlessness take place, and was noted to be a very useful tool for the evaluation of dyspnea. The second measurement is the total length of breath hold time. This provides feedback of the upper limit of toleration of breathlessness and is influenced by behavioural characteristics such as willpower and determination. As the first test is not influenced by training effect or behavioural characteristics, it can be deduced that it is a more objective measurement.

Respir Physiol Neurobiol. 2009 May 30;167(1):20-5. Epub 2008 Nov 25. Pathophysiology of dyspnea evaluated by breath-holding test: studies of furosemide treatment. Nishino T.

Control Pause and exercise tolerance

Eighteen patients with varying stages of cystic fibrosis were studied to determine the value of the breath hold time as an index of exercise tolerance. The breath hold times of all patients were measured. Oxygen uptake (Vo2) and carbon dioxide elimination was measured breath by breath as the patients exercised. The researchers found a significant correlation between breath hold time and VO2 (oxygen uptake), concluding "that the voluntary breath-hold time might be a useful index for prediction of the exercise tolerance of CF patients."

Eur J Appl Physiol. 2005 Oct;95(2-3):172-8. Epub 2005 Jul 9 Relationship between breath-hold time and physical performance in patients with cystic fibrosis.Barnai M, Laki I, Gyurkovits K, Angyan L, Horvath G.

Breath Hold and breathlessness

Results from a study of 13 patients with acute asthma, concluded that the magnitude of breathlessness, breathing frequency and breath hold time correlated with severity of airflow obstruction and secondly breath hold time varies inversely with dyspnea magnitude when it is present at rest.

Rev Invest Clin. 1989 Jul-Sep;41(3):209-13. Rating of breathlessness at rest during acute asthma: correlation with spirometry and usefulness of breath-holding time.Perez-Padilla R, Cervantes D, Chapela R, Selman M.

Roger Price on Control Pause

“the breath-hold or control pause is a measurement of the point at which the body initiates breathing. If it is used at the start of a period of reduced breathing it will provide a baseline indication of trigger response. If the period of reduced breathing has been effective a control pause should indicate that the response time has lengthened - and that is the goal.

It is a similar concept to going on a diet. The bathroom scale is the indicator of the starting point, the reduced eating is the key and the scale indicates the level of success. The scale has NOTHING to do with the diet. It can be any colour and can even be a couple of kilograms under or over - this will have no bearing on the success of the reduced eating program.

The simple fact is that some people simply cannot do a control pause or breath hold - for whatever reason - and this causes them not to get the benefit from the reduced breathing exercises as they feel that they have failed.”

From Weblog, 2012

BIBH survey of practitionersButeyko Institue of Breathing and Health, Australia

1. Based on over 11,000 clients, estimates from the 2010 BIBH survey suggest that breathing retraining using the BIM show significant improvement in sleep for >95 percent of clients with sleep apnoea who undertook BIM courses.2. Estimates from the 2010 survey also suggest that approximately 80 percent of clients were able to cease using their CPAP machine.3. Sleep medicine research suggests that breathing pattern disorder, i.e. intermittent or chronic hyperventilation, is common in people with sleep apnoea.4. Independent clinical trials in the medical literature indicate that the Buteyko method of breathing retraining is successful in improving disordered breathing patterns and reducing hyperventilation.175. Although not explored in association with breathing retraining, research in the medical literature appears to support the Buteyko hypothesis on sleep apnoea.6. Increasing numbers of people are currently being diagnosed with sleep apnoea and increasing numbers of people with sleep apnoea are attending Buteyko Institute courses.Therefore it is necessary to ascertain scientifically how effective the BIM is for sleep apnoea.7. Currently, limited treatment options are available for many people with sleep apnoea. If validated scientifically, the Buteyko Institute method of breathing retraining would provide a further treatment option for people who cannot tolerate CPAP or oral appliances.8. Sleep apnoea is a condition with serious co-morbidities, therefore further effective treatment options are urgently required, in light of significant non-adherence with currently availabletreatments.9. Compared with existing treatments for sleep apnoea, the cost of the Buteyko Institute Method of breathing retraining is very economical. Buteyko Institute Method of breathing retraining course fees are estimated at approximately 25 percent of the cost of CPAP or oral appliances. In addition, there are no ongoing expenses in relation to the upkeep and maintenance of equipment or appliances.10. The BIBH 2010 survey suggests that people suffering from sleep apnoea are likely to comply with Buteyko Institute Method of breathing retraining because this method of breathing retraining:a. is effective b. is safe and non-invasivec. does not have side effectsd. is convenient in comparison with current treatment optionse. is economical in comparison with current treatment optionsf. is an acceptable and appealing option compared with current treatment optionsg. does not involve the use of equipment or devicesh. does not involve ongoing maintenance or upgrading of equipment.

Oral Myology

Creating objective measure of something immeasurable

Journal of Oral Rehabilitation 2012 39; 744–753

Validity of the ‘protocol of oro-facial myofunctionalevaluation with scores’ for young and adult subjects

C. M. DE FELI´CIO*, A. P. M. MEDEIROS* & M. DE OLIVEIRA MELCHIOR

OM helps OSA

• RCT, n=16 adults• 3 months of exercise training reduced the severity of OSAS by 39% (by AHI and lowest O2 sat)• a reduction in snoring, daytime sleepiness, and quality of sleep score• significant reduction in neck circumference• muscle training while awake will reduce upper airway collapsibility during sleep in patients with OSAS.• improvements in several subjective sleep scales

Effects of Oropharyngeal Exercises on Patients withModerate Obstructive Sleep Apnea Syndrome

Ka´tia C. Guimara˜es, et alAM J OF RESP AND CRITIC CARE MED VOL 179 2009, p962-966

•Patients with OSAS typically had •elongated and floppy soft palate and uvula, •enlarged tongue•inferior displacement of the hyoid bone

SLEEP 2012: Associated Professional Sleep Societies 26th Annual Meeting. Abstract #1050. Presented June 12, 2012.