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

2. OBSTRUCTIVE SLEEP APNEA IN CHILDREN IS A SERIOUS PROBLEM
ADHD
HYPERTENSION
ENEURESIS
HYPOTROPHIC FACES AND JAWS
FAILURE TO THRIVE
DELAYED DEVELOPMENT OF MOTOR SKILLS
LEARNING DISORDERS
COGNITIVE DISORDERS
EXECUTIVE DYSFUNCTION
BEHAVIORAL DISORDERS
ARE SOME OF THE COMORBID SYMPTOMS OF KIDS’ OSA
DISRUPTED SLEEP
CARDIOVASCULAR PROBLEMS

3. CHILDREN WITH OSA GENERATE 2
CHILDREN WITH OSA GENERATE 2.6 TIMES THE AMOUNT OF HEALTHCARE EXPENSES AS NON-OSA CHILDREN

4. THESE KIDS ARE NOSE BREATHERS, SLEEPING WITH THEIR MOUTHS CLOSED
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

5. THESE KIDS ARE SLEEPING WITH THEIR MOUTHS OPEN
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

6. THE AIRWAY COLLAPSES DURING AN APNEA EPISODE IN SLEEP CHILDREN WHO HAVE OSA HAVE SMALLER AND MORE OBSTRUCTED AIRWAYS THAN NON-OSA CHILDREN

7. THE SAME STRUCTURAL AND FUNCTIONAL PROBLEMS CREATED BY AIRWAY OBSTRUCTIONS DURING SLEEP RESULT IN INTERMITTENT HYPOXIAS AND HYPERCARBOXIAS IN CHILDREN

8. THESE SAME CONDITIONS EXIST DURING THE DAY AND AFFECT GROWTH, POSTURE, OROFACIAL STRUCTURE AND FUNCTION, NEUROLOGICAL AND CARDIOVASCULAR FUNCTION, LEARNING ABILITY AND BEHAVIOR

9. THE GOLD STANDARD FOR DIAGNOSIS OF SLEEP DISORDERED BREATHING IS A POLYSOMNOGRAPHIC STUDY PERFORMED AT A SLEEP LAB

10. 1. UARS IS MORE COMMON IN KIDS THAN OSA
2. FLOW LIMITATION (UARS) CAN BE MEASURED WITH NASAL PRONGS
3. MILD CRANIOFACIAL DEVELOPMENTAL ANOMALY IS OFTEN SEEN IN KIDS WITH UARS
4. EXAMINATION TO ASSESS THE NEED FOR ORTHODONTICS IS THE SUBJECT OF TODAY’S LECTURE

11. TODAY WE ARE DISCUSSING DIAGNOSTIC FACTORS FOUND ON EXAMINATION THAT SUGGEST CONSERVATIVE TREATMENT AND/OR PREVENTION

12. EARLY RECOGNITION AND PREVENTION ARE THE KEY WORDS

13. FAILURE TO TREAT SLEEP DISORDERED BREATHING IN CHILDREN PUTS THEM AT RISK FOR VERY SERIOUS HEALTH PROBLEMS LATER IN LIFE

14. THE EVIDENCE IS INDISPUTABLE THAT EARLY DIAGNOSIS AND TREATMENT OF SLEEP BREATHING DISORDERS IN KIDS IS MANDATED

15. THERE IS STRONG EVIDENCE THAT NO ONE TREATMENT MODALITY GETS 1OO% SUCCESSFUL RESULTS THIS LECTURE EMPHASIZES MULTIDISCIPLINARY INVOLVEMENT
PEDIATRICIAN
DENTIST
SLEEP SPECIALIST
MYOFUNCTIONAL THERAPIST
ALLERGIST
PULMONOLOGIST
SURGEON
NEUROLOGIST

16. 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,

18. 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

19. 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

20. 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

21. ORTHODONTIC TX AFTER AGE 12 VIRTUALLY ASSURES RELAPSE
BY AGE 4, 60% OF FACIAL GROWTH IS COMPLETE BY AGE 6, 80% OF FACIAL GROWTH IS COMPLETE BY 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

22. 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

24. 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 PASSAGES
KIDS WHOSE AIRWAYS DO NOT COLLAPSE AT NIGHT AS A RESULT OF PALATAL EXPANSION ALSO ENJOY IMPROVED BREATHING DURING THE DAY

30. 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

31. BREATHING IS A PRIMAL FUNCTION NECESSARY FOR SURVIVAL THE RESPIRATORY CENTRAL PATHWAY MAINTAINS THE PATENT AIRWAY AND DOMINATES REFLEX CONTROL OF THE OROPHARYNX IT SUPERCEDES ALL OTHER REFLEXES

32. 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

33. NOSE BREATHER: NARES FLARE
NOSE BREATHER VS MOUTH BREATHER SNIFF 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

34. 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

35. THE LOWERED TONGUE POSITION THE NARROWING OF THE AIRWAY AND SUBSEQUENT INCREASED COLLAPSIBILITY DURING SLEEP PREDISPOSE TO PEDIATRIC OSA, SNORING AND UARS

36. 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

37. THE TEETH TOUCH IN A POSITION OF MAXIMUM OCCLUSION
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

38. 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

39. MOUTH BREATHER, LIPS APART AT REST, CHRONIC DRY CHAPPED LIPS

40. STRAINED FACIAL MUSCLES TO ATTAIN LIP CLOSURE
STRAINED FACIAL MUSCLES TO ATTAIN LIP CLOSURE. NOTE LOWER LIP PUSHING IN

41. MALOCCLUSION EVIDENT ON SMILE

42. LIPS PUSHED LOWER TEETH IN. TONGUE PUSHED UPPER TEETH OUT

43. NATURAL REST POSITION

44. SWALLOWING – NOTE LIPS

45. ANTERIOR TONGUE THRUST

47. REST POSITION

48. SWALLOWING NOTE STRAINED LIPS

50. 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

51. NORMAL ORTHODONTIC FORCE
The need to retrain deleterious muscle forces is imperative to successful orthodontic treatment

52. 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.

53. STEP PLANE OF OCCLUSION

54. SHORT FACE NOTE: PROTRUDING UPPER LIP RETRUDED LOWER JAW
DEEP LABIAL GROOVE
LOW TONGUE POSITION
5. THIS KID IS A MOUTH BREATHER
6. HEAD FORWARD POSTURE

55. 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

56. LONG FACE NOTE: THE STRAINED CLOSED LIP POSTURE
STRAINED MENTALIS MUSCLE
NARROW NOSTRILS INDICATIVE OF NASALLY OBSTRUCTED BREATHING
ALLERGIC SHINERS
HOW DO YOU THINK THE TEETH LOOK ?

57. ALL KIDS WITH MALOCCLUSION DO NOT HAVE OSA
UNDERSTANDING THE RELATIONSHIPS BETWEEN MALOCCLUSIONS AND BREATHING PROBLEMS MAY INCREASE QUALITY OF LIFE AND PREVENT OSA

58. SURGICAL REMOVAL OF TONSILS ADENOIDS AND OTHER OBSTRUCTIONS TO NASAL BREATHING DOES NOT ELIMINATE THE LEARNED COMPENSATORY REFLEXES FOR LIP, SWALLOW AND TONGUE FUNCTION

59. THERE ARE TWO DISTINCT TYPES OF ORAL FUNCTION – TONIC AND PHASIC
TONIC: LIP AND TONGUE RESTING POSTURE
PHASIC: SWALLOWING, SPEECH AND BREATHING

60. 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

61. 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

62. FLUTTER DVD