PEDIATRIC SLEEP APNEA AND ITS CLOSE RELATIVE UPPER AIRWAY RESISTANCE SYNDROME Allen J Moses, DDS Assistant Professor Rush University ajmosesdds@sbcglobal.net http://www.kidsapnea.com

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

CHILDREN WITH OSA GENERATE 2 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 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 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

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

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 DENTIST SLEEP SPECIALIST MYOFUNCTIONAL THERAPIST ALLERGIST PULMONOLOGIST SURGEON NEUROLOGIST

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

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

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 PASSAGES KIDS 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 SURVIVAL THE 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: 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

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 POSITION THE NARROWING OF THE AIRWAY AND SUBSEQUENT INCREASED COLLAPSIBILITY DURING SLEEP PREDISPOSE TO PEDIATRIC 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 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

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 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 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

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 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 ?

ALL KIDS WITH MALOCCLUSION DO NOT HAVE OSA UNDERSTANDING 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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