Sleep disordered breathing in children--a review and the role of a pediatric dentist

Among the many factors important in children's development is sleep. Sleep disorders can impair children's sleep and lead to negative consequences. The most common sleep disordered breathing (SDB) in children is obstructive sleep apnea (OSA). One of the main causes of childhood SDB is enlargement of the tonsil tissues and, in most cases, their removal serves as an ultimate treatment of SDB. However, it remains unclear what proportion of children with enlarged tonsil tissue suffer from SDB. Dentists are becoming increasingly aware of the issue of SDB as they are sometimes involved in treatment of this condition using oral appliances. Moreover, as dentists often look into children's mouths, they can play an active role in identifying those with enlarged tonsils and referring them for sleep assessment. This review focuses on the diagnosis and treatment of SDB and also on the utility of oral appliances in the management of this disorder.     

Sleep disordered breathing and dentistry: Waking up to reality

Sleep Disordered Breathing (SDB), especially obstructive sleep apnea (OSA) is increasingly recognized today as having health implications for individuals who are suffering from this condition, and especially those who remain undiagnosed and may not be receiving the necessary treatment. OSA has gained significant attention by the dental and orthodontic communities due to its prevalence, its short and long term mental and systemic health consequences, and its manifestation within the vicinity of the dentofacial region. It would appear that many dental professionals, including orthodontists, have taken not only significant responsibility in diagnosing and managing OSA by themselves but also have availed themselves of the financial benefits of this new found means of income and practice growth. The goal of this paper is to examine the various controversies surrounding this issue by reviewing the related literature, and discuss what should be the actual role of our specialty in the diagnosis and management of sleep apnea in clinical practice.     

Oral appliance management of obstructive sleep apnea: a case report

Obstructive sleep apnea (OSA) and snoring are common related conditions with major health and social implications. OSA is a progressive disease with symptoms of daytime sleepiness and chronic cardiovascular morbidity A mandibular advancement oral appliance is the only nonsurgical management modality available if continuous positive airway pressure (CPAP) cannot be tolerated. A patient who had been diagnosed with OSA was successfully treated but developed a posterior open bite and symptomatic temporomandibular joints (TMJ). An integrated approach to managing his OSA and TMJ conditions enabled him to have a comfortable and stable bite and to continue using his obstructive sleep apnea appliance. Management of OSA with an oral appliance should be handled by a dentist who is trained and experienced in the overall care of oral health, temporomandibular joints, dental occlusion, and associated structures. A team approach starting with the diagnosis of OSA by a physician and management by a dentist is described.     

Sleep disorders and oral devices.

Many patients with upper airway sleep disorders can be successfully treated with oral appliance therapy. It is necessary for dentists to recognize these patients and refer them to a physician for further evaluation. Dentists must not become the primary care providers for these patients or attempt to treat a medical problem with an oral appliance without a proper diagnosis, which usually requires a sleep study and can only be diagnosed by a physician. Dentists must also be able to treat the patients referred by physicians and to follow accepted procedures when fabricating, inserting, titrating, and providing follow-up care for oral appliance therapy. In addition, the dental community needs to continue to heighten the awareness in their local medical community and in their patient population as to the possible contribution of oral appliance therapy to the management of snoring and some of the sleep-related breathing disorders.     

Dentistry's role in obstructive sleep apnoea. Review and case report

Obstructive sleep apnoea (OSA) has been associated with many life-threatening conditions but has only recently appeared in the dental literature. Dental appliances and orthognathic surgery are two strategies which are currently used in the treatment of sleep apnoea. This article provides a background on OSA and these treatment approaches, and discusses the potential risks and benefits of each. A case is reported to illustrate the use of a dental appliance in the treatment of OSA.     

Role of dental sleep medicine in management of patients with obstructive sleep apnea disorders using a team approach

Objective: Obstructive sleep apnea (OSA) is a significant social and health issue. An integrated multidisciplinary approach to OSA management may be the most effective owing to its multifactorial etiology. In this study, we evaluated the frequency and efficacy of various treatment modalities for OSA administered via an integrated care delivery model, and assessed the role of dental sleep medicine as part of a multidisciplinary team.

Materials and Methods: We retrospectively evaluated 1115 patients with OSA treated at the Tokyo Medical University Hospital’s Outpatient Clinic for OSA by a multidisciplinary team under one roof. The various treatment methods included the following: continuous positive airway pressure (CPAP), oral appliance (OA), surgery, and behavioral treatment.

Results: The patient number of study group was as follows: 771 (69.1%) CPAP; 240 (21.5%) OA; 76 (6.8%) behavioral treatment and 28 (3%) surgery. Because significantly fewer patients underwent surgery, there was a discrepancy between the recommended first-choice treatment and the actual treatment. A statistically significant number of younger patients in each treatment group underwent surgery. Success rate of OA and MMA were 74.4 and 80%, respectively.

Conclusions: Proper selection of primary treatment to manage patients with OSA was possible under one-roof system that included dental sleep medicine.     

Modified mandibular advancement appliance for an edentulous obstructive sleep apnea patient: a clinical report

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder with periodic reduction or cessation of airflow during sleep. It is associated with loud snoring, disrupted sleep and observed apneas with prevalence up to 54% in elderly people. Treatment of OSA varies from simple measures such as dental appliances and nasal continuous positive airway pressure (CPAP) to surgical procedures like uvulopalatopharyngoplasty and tracheostomy. Dental appliances are a viable nonsurgical treatment alternative in patients with OSA, of which mandibular advancement appliances are most common. Edentulism which contributes to the worsening of OSA reduces the number of available therapeutic strategies and is considered a contraindication to oral appliance therapy. This clinical report describes the treatment of a 61-year old edentulous OSA patient for whom a modified mandibular advancement appliance was designed. The patient reported an improvement in AHI index and he was satisfied with the modified appliance. This clinical report describes the newer technique of fabricating oral appliance for edentulous OSA patient.     

A simple appliance for the management of obstructive sleep apnoea--the MEDUNSA Anti-Snoring Device (MASD).

Obstructive sleep apnoea (OSA) is a breathing abnormality that occurs during sleep. It is characterised by snoring and episodes of sleep disturbance that can occur from 10 to 500 times per night causing excessive daytime exhaustion. A large tongue and a retrognathic mandible have been listed as aetiological factors. Orthodontic appliances that have been used to manage the condition are usually complicated, uncomfortable, expensive and delicate. The aim of this clinical procedure is to design a simple, inexpensive, durable and user-friendly appliance that can be used in the management of OSA. The procedure involves taking upper and lower impressions of a patient with OSA and articulating the study casts in a registered protrusive bite. Gum guards of the dental arches are then constructed and fused together in the protrusive position with a 5 to 10 mm open bite. The forward and downward advancement of the mandible caused by the appliance drags the tongue and other structures along, and thus opens the posterior pharyngeal airway during sleep. For ease of reference this appliance has been named the MEDUNSA Anti-Snoring Device (MASD) and it differs from similar appliances in that it is entirely toothborne and does not impinge on the surrounding soft tissues. The MASD was used in a patient with OSA at the MEDUNSA Oral Health Centre. Pre-treatment and post treatment airway dimensions from the lateral cephalograms confirm an increase of 50 per cent in airway size at the level of the epiglottis with a corresponding reduction in clinical symptoms. The MASD is an extremely valuable tool to dentists, orthodontists, as well as any other health professionals managing sleep-breathing abnormalities. While the MASD has been successful in this preliminary case, clinical trials are under way to further evaluate the MASD.     

Obstructive sleep apnea: diagnosis, medical management and dental implications

BACKGROUND: Patients with undiagnosed obstructive sleep apnea (OSA) represent a major public health problem, and studies suggest that the incidence of OSA may be even higher than estimated. TYPES OF STUDIES REVIEWED: The authors reviewed current literature describing comorbidities of patients with OSA. RESULTS: Sleep medicine is a relatively new field. Dental practitioners may lack educational exposure and, as a result, feel uncomfortable asking their patients sleep-related questions. While patients with well-controlled OSA present few difficulties for routine dental treatment, it is imperative that health care professionals understand the comorbidities associated with OSA and that untreated OSA may contribute to increased morbidity and mortality. CLINICAL IMPLICATIONS: Dental professionals have a unique doctor-patient relationship that affords them a role in recognizing sleep disorders by exploring the history of patients who are sleepy.     

Impact of nasal airway obstruction on dentofacial development and sleep disturbances in children: preliminary notes

Respiratory disorders in the upper respiratory tract during sleep are most often part of a continuous pathological process of long standing. Schematically, three clinical syndromes with increasing severity are described: breathing with the mouth open, snoring and sleep apneal hypopnea syndrome. Obstructive sleep apnea syndrome (OSAS) is a subtle, but severe sleep disorder of early childhood. It is often difficult to detect and may have long-term consequences, including failure to thrive, behavioral disturbances, developmental delay, and cor pulmonale. These conditions always include a functional maxillofacial perturbation, which may be associated with a constitutional or acquired morphological disorder. Pediatric dentists must be aware of the problems connected with mouth breathing and OSAS (obstructive sleep apnea syndrome) in children as any delay in diagnosis and treatment may cause prolonged morbidity. They also have a role in the diagnosis and co-management of these patients because the signs and symptoms may be recognizable in the dental practice. Besides the medical approach itself, the treatment sometimes is surgical, always orthopedic: the earlier it is initiated, the more effective, simple and unrestraining it is. The aim of this work is to focus attention on the early diagnosis and prevention of these pathologies. Diagnostic guidelines will be illustrated.     

Two different degrees of mandibular advancement with a dental appliance in treatment of patients with mild to moderate obstructive sleep apnea

The objective of this study was to evaluate the effect of 2 different degrees of mandibular advancement, 50% vs. 75% of maximum protrusive capacity, on somnographic variables after 1 year of dental appliance treatment in patients with mild to moderate obstructive sleep apnea (OSA). A further purpose was to compare the number of adverse events on the stomatognathic system. In a prospective study, 74 male patients were randomly allocated to receive a dental appliance with either 50% (38 patients) or 75% mandibular advancement (36 patients). After 1 year of treatment, 55 patients completed the follow-up. Somnography was performed to measure treatment effects before and 12 months post-treatment. The apnea, apnea/hypopnea, and oxygen desaturation indices decreased significantly in both groups after 1 year (P < 0.001); however, there were no differences between the groups. Normalization (apnea index < 5 and apnea/hypopnea index < 10) was observed in 79% in group 50 and in 73% in group 75. Few patients (< 5%) reported symptoms from the stomatognathic system except for headache (> once a week), which was reported in one-third of the patients. Headache was significantly more infrequent after 1 year of treatment in both groups (P < 0.001). No serious complications were observed except for 2 patients who reported a painful condition from the temporomandibular joint in either group. In conclusion, mandibular advancement with a dental appliance effectively reduces the sleep-breathing disorder measured as frequency of apneas, and a pronounced mandibular advancement did not show a greater improvement of the medical problem compared to less advancement for patients with mild to moderate OSA. On the basis of few adverse events in the stomatognathic system or other complications we can recommend dental appliance treatment and, for patients with mild to moderate obstructive sleep apnea, not starting treatment by more than 50% mandibular advancement.     

Obstructive sleep apnoea and the need for its introduction into dental curricula

Obstructive sleep apnoea (OSA) is a major health problem which causes blood oxygen desaturation that may initiate a cascade of events via inflammatory cytokines and adrenocorticotrophic hormone that may have impact upon quality of life and lead to potential life‐threatening events. Even though OSA affects an increasing number of individuals, the role of dental practitioners in recognition, screening and management has not developed accordingly. The goal of this article was to provide updated information to dental practitioners on pathophysiology, consequences and treatment options of OSA with a focused discussion on oral appliance (OA) therapy, as this topic is not routinely included in current dental curricula of many dental schools. Additionally, we present a template dental curriculum for predoctoral and/or postdoctoral students in education regarding sleep disordered breathing.     

The role of oral appliances in treating obstructive sleep apnea

BACKGROUND: Sleep-related breathing disorders are common and often are associated with vascular complications such as arterial hypertension, coronary heart disease and stroke. The most widely studied form of these disorders is obstructive sleep apnea. Patients usually are diagnosed with obstructive sleep apnea years after the onset of symptoms, which generally are nonspecific and include excessive daytime sleepiness, chronic fatigue and habitual snoring. The risk factors for sleep apnea are obesity, advancing age, male sex and maxillofacial abnormalities. This review focuses on the diagnosis and treatment of obstructive sleep apnea and, specifically, on the utility of oral appliances in the management of this disorder. METHODS: The review is based on a MEDLINE search for articles in English on this topic. The article discusses results of randomized studies and prospective case series. CLINICAL IMPLICATIONS: Several treatment options are quite effective. Nasal continuous positive airway pressure, with an overall acceptance rate of 70 percent, is the most widely used treatment modality. Maxillofacial surgery, although effective, is reserved for patients who have not responded to the more conventional therapies. Newer methods include application of oral appliances. Oral appliances have been shown to alleviate the severity of respiratory disturbances during sleep by about 60 percent, with an overall acceptance rate of 75 percent. The long-term complications generally are minor and are related to occlusal changes and temporomandibular joint discomfort. CONCLUSIONS: With the advent of oral appliances, dentists are increasingly involved in managing the care of patients with sleep-related breathing disorders. Further studies are needed to determine the long-term complications of this type of intervention for the treatment of sleep-related breathing disorders.     

Interactions between sleep disorders and oral diseases

Dental sleep medicine is a rapidly growing field that is in close and direct interaction with sleep medicine and comprises many aspects of human health. As a result, dentists who encounter sleep health and sleep disorders may work with clinicians from many other disciplines and specialties. The main sleep and oral health issues that are covered in this review are obstructive sleep apnea, chronic mouth breathing, sleep‐related gastroesophageal reflux, and sleep bruxism. In addition, edentulism and its impact on sleep disorders are discussed. Improving sleep quality and sleep characteristics, oral health, and oral function involves both pathophysiology and disease management. The multiple interactions between oral health and sleep underscore the need for an interdisciplinary clinical team to manage oral health‐related sleep disorders that are commonly seen in dental practice.     

Management of obstructive sleep apnea: A dental perspective.

Sleep disordered breathing is a term which includes simple snoring, upper airway resistance syndrome, and obstructive sleep apnea (OSA). Simple snoring is a common complaint affecting 45% of adults occasionally and 25% of adults habitually and is a sign of upper airway obstruction. Snoring has also been identified as a possible risk factor for hypertension, ischemic heart disease, and stroke. The role of dentistry in sleep disorders is becoming more significant, especially in co-managing patients with simple snoring and mild to moderate OSA. The practicing dental professional has the opportunity to assist patients at a variety of levels, starting with the recognition of a sleep-related disorder, referring patients to a physician for evaluation, and assisting in the management of sleep disorders. Obesity is the main predisposing factor for OSA. In nonobese patients, craniofacial anomalies like micrognathia and retrognathia may also predispose to OSA. Diagnosis of OSA is made on the basis of the history and physical examination and investigations such as polysomnography, limited channel testing, split-night testing, and oximetry. Nocturnal attended polysomnography, which requires an overnight stay in a sleep facility, is the standard diagnostic modality in determining if a patient has OSA. As far as treatment is concerned, the less invasive procedures are to be preferred to the more invasive options. The first and simplest option would be behavior modification, followed by insertion of oral devices suited to the patient, especially in those with mild to moderate OSA. Continuous positive airway pressure (CPAP) and surgical options are chosen for patients with moderate to severe OSA. The American Academy of Sleep Medicine (AAOSM) has recommended oral appliances for use in patients with primary snoring and mild to moderate OSA. It can also be used in patients with a lesser degree of oxygen saturation, relatively less day time sleepiness, lower frequency of apnea, those who are intolerant to CPAP, or those who refuse surgery. Oral appliances improve the blood oxygen saturation levels as they relieve apnea in 20-75% of patients. They reduce the apnea-hypopnea index (AHI) by 50% or to < 10 events per h. Oral appliances also reduce the AHI to normal in 50-60% patients.     

Dental considerations in upper airway sleep disorders: A review of the literature

STATEMENT OF PROBLEM: Upper airway sleep disorders are becoming recognized as common medical concerns. Multiple treatment options have been advocated, including the use of dental devices. Dental practitioners are being asked by the medical profession to become a part of the treatment team. This may be a challenging task because of the large number of dental devices available, rapid advancement in the understanding of this disease, and numerous publications. PURPOSE: This article reviews the anatomic features and etiologic factors of upper airway sleep disorders and medical and dental treatment options. METHODS: The literature review was conducted with an accepted literature research tool, PubMed, developed by the National Library of Medicine. Key words searched included "obstructive sleep apnea," "sleep apnea," "sleep disorders," and "snoring". CONCLUSION: Dental devices are indicated in snoring and mild-to-moderate obstructive sleep apnea patients after medical evaluation and referral.     

The role of the dentist in the diagnosis and management of pediatric obstructive sleep apnea

The objective of this article is to review the role of the dentist in the early diagnosis of pediatric obstructive sleep apnea (OSA) and to provide an in-depth review of the best evidence-based practices available to treat and/or to refer these patients for intervention.Material and methodsA narrative review was performed using indexed data bases (PubMed, Medline, EMBASE, OVID, Scopus and Cochrane) up to year 2020, and approximately 1000 articles were reviewed. The articles included were those with the best information provided.ResultsDetailed review of the literature suggests that the role of the dentist has been redefined owing to their expertise in the orofacial region. Every patient consulting a dental practice is not merely a dental patient; he/she also requires a comprehensive medical review. The role of the dentist is pivotal in pediatric patients once diagnosed with OSA; as the patients grow, growth modification can be achieved, and future management will be easier. Initiating dental treatments during growth can benefit patients two-fold, saving them from malocclusion, and intervening in orofacial structural growth can help to avoid cumbersome treatments, such as CPAP and various surgeries. Proper diagnosis and management of systemic illnesses can prevent compromised quality of life, delays in treatment, morbidity and, in some cases, mortality.     

Dental appliances for the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a syndrome in which the airflow created from breathing ceases through the upper airway although diaphragm movement continues. Resulting complications include severe daytime sleepiness, morning headaches, loud snoring, and disturbed nighttime sleep. Patients affected with OSA are frequently hypertensive and can have dangerous cardiac arrhythmias. The diagnosis of OSA requires an all-night polysomnographic recording; neither snoring nor other subjective complaints constitute adequate criteria for treatment. The treatment objective for OSA is to maintain airway patency. A potential treatment discussed here is temporary advancement of the mandible or tongue during sleep with the use of dental appliances.