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Educational aims A Checklist for Evaluation This article is written in behalf of all clinical team members, to orient of Potential Airway & each of us in the basic understand- ing of the of dys- functional and com- Breathing Disorders monly found in our dental practice population. The dedicated clinician by DeWitt C. Wilkerson, DMD is encouraged to read each of the ref- erences from this practical article. Expected outcomes n October 2017, the American Dental Association (ADA) re- Dental Sleep Practice subscrib- leased a policy statement addressing dentistry’s role in sleep-re- ers can answer the CE questions on 1 page 26 to earn 2 hours of CE from Ilated breathing disorders. The policy encourages dental pro- reading this article. Correctly answer- fessionals to screen their patients for Obstructive Sleep ing the questions will demonstrate the reader will: (OSA), Upper Airway Resistance Syndrome (UARS), and other • Gain a basic understanding of the breathing disorders. The ADA advocates working in collabora- signs and symptoms of dysfunc- tion with other trained medical colleagues and emphasizes the tional breathing and sleep. • Have a practical clinical guide effectiveness of intra-oral appliance therapy for treating patients which can be implemented im- with mild to moderate OSA and CPAP-intolerant patients with mediately. severe OSA.

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With the endorsement of the ADA, well. Approximately one in three snorers also screening and treating sleep-related breath- suffers from obstructive . ing disorders has become the newest focus of integrative dental medicine. The pur- 3. SLEEP APNEA - + pose of this article is to provide a simpli- Have you been diagnosed with Sleep Ap- fied Checklist to guide the dental team in nea or been observed to stop breathing in reviewing each patient’s: your sleep? • History (signs & symptoms) is a very seri- • Clinical Evaluation ous breathing disorder that has significant • Screening & Testing systemic effects due to mechanical col- lapse of the posterior throat airway. An History (signs & symptoms) apneic event occurs when breathing 1. MOUTHBREATHER - + ceases for 10 seconds or longer accom- History Are you aware being a mouth breather? panied by drops in oxygen saturation in 1. Mouthbreather is considered dysfunc- the bloodstream. During sleep, multiple 2. Snore tional breathing, because it bypasses the events in intervals of several minutes 3. Sleep Apnea critical physiologic benefits of nasal breath- or longer can mimic the experience of 4. Poor Sleep Quality 2 ing. Through the nose, air is humidified, and stimulate activation of the 5. Daytime Sleepiness warmed, sterilized/anti-microbial effect of Sympathetic Nervous System, “Fight or 6. Nasal Congestion nitric oxide produced in the para-nasal si- Flight” response. Stress hormones, in- 7. Forward Head nuses, and the breathing rate is controlled cluding Cortisol, are released into the Posture to help maintain an optimum carbon diox- bloodstream, producing an acute ex- 8. Tongue-tie ide-oxygen ratio in the bloodstream (Bohr citation of the heart rate. The increase 9. Chronic Effect). Mouth breathing eliminates the pos- in blood flow is an attempt to deliver 10. Deviated Septum sibility of ideal physiologic breathing, al- needed oxygen throughout the body. lowing “dirty air” containing microbes, pol- Chronic elevated cortisol levels in the lutants, pesticides, smog, allergens, pollen, blood can produce several deleterious and spores, to name a few, to pass through effects including increased blood pres- the mouth straight to the lymphoid tissues sure, cardiac arrhythmia, insulin resistance, of the adenoids and tonsils. This can result and leptin/ghrelin imbalance. An increased in both inflammation and infection in the hunger drive can be stimulated by imbalanc- posterior throat. es between leptin and ghrelin. (CSA) is a CNS dis- 2. SNORE - + order in which the respiratory center in the Are you aware of in your sleep? brain fails to transmit a signal to the body to Snoring is a sign of airway blockage as the inhale. CSA frequently occurs among peo- tissues of the soft palate vibrate against the ple who are seriously ill from other causes: posterior wall of the pharynx. This can be ac- chronic heart failure, diseases of and injuries companied by the tongue dropping back as to the breathing control centers in the brain-

Dr. DeWitt “Witt” Wilkerson graduated from the University of Florida, College of Dentistry in 1982, the same year he joined the Dawson group private practice in St. Petersburg, Florida, and where he presently practices. He is Past President of the American Equilibration Society, Immediate Past-President of the American Academy for Oral-Systemic Health, Senior Faculty/Lecturer and Director of Dental Medicine at the Dawson Academy, an Adjunct Professor of Graduate Studies at the University of Florida, College of Dentistry, and Past Associate Faculty and Special Lecturer at the L.D. Pankey Institute. Dr. Wilkerson lectures both nationally and internationally on the subjects of Restorative Dentistry, Dental Occlusion, TM Disorders, Airway/Dental , and Integrative Dental Medicine. He has taught over 600 days of lectures and hands-on instruction at the Dawson Academy. Personally, Witt and his wonderful wife, Pat, have been married 37 years and are the proud parents of Todd, Whitney, Ryan, and a beautiful 3 year old granddaughter, Carolina. The Wilkerson family has been privileged to participate in many dental missions trips including Romania, Kenya, and Nicaragua.

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stem, Parkinson’s disease, stroke, kidney fail- 6. NASAL CONGESTION - + ure, and even severe arthritis with degener- Do you experience frequent nasal con- ative changes to the cervical spine and base gestion or difficulty breathing through of the skull. It is seen among users of opiates. your nose? Idiopathic CSA is a description used when Nasal congestion due to allergies from the cause is unknown. food or environment, nasal stenosis, deviated Mixed Apnea describes the simultaneous septum, nasal polyps, turbinate enlargement, occurrence of both OSA and CSA. and/or acute and chronic sinusitis, will affect breathing and often cause a conversion to 4. POOR SLEEP QUALITY - + dysfunctional mouth breathing. Eustachian Do you sleep poorly or wake up during tube blockage can produce a fullness feeling the night? in the ears. Breathing disorders during sleep disrupt the normal sleep pattern. Stimulation of the 7. FORWARD HEAD POSTURE - + Sympathetic “Fight or Flight” response to de- Does your neck bother you and do you find creased oxygen levels, the release of steroid yourself in a forward head posture? hormone Cortisol from the Adrenal glands, “Mouth-breathing Syndrome” is char- and increases in heart rate are all involved acterized by significant nasal obstruction, in producing arousals from deeper to lighter whereby an effort to overcome this resistance sleep levels or even waking up. Frequent uri- increases the work of accessory muscles nation at night is a common side effect. of inspiration. Furthermore, forward head posture, common among mouth breathers, 5. DAYTIME SLEEPINESS - + facilitates the air to enter the mouth which Do you feel tired and sleepy during the day? can lead to a deterioration of the pulmonary Failure to spend adequate time in deeper function. Chronically, the hyperactivity of sleep stages produces non-restorative sleep the neck muscles may be associated with and its consequences: daytime fatigue and cervical changes that, as a result, can influ- sleepiness. ence temporomandibular disorders (TMD) and spine cervical disorders.3

8. TONGUE-TIE - + Chronic cough and Do you have a tongue-tie or any tongue similar throat issues restrictions affecting sucking, swallowing or speech? are highly correlated A short lingual frenulum has been associ- with Sleep Apnea and ated with difficulties in sucking, swallowing and speech. The oral dysfunction induced Gastroesophageal Reflux by a short lingual frenulum can lead to oral- Disease (GERD), which facial dysmorphosis, decreasing the size of upper airway support. Progressive change in- often occur together. creases the risk of upper airway collapsibility during sleep.4

9. CHRONIC COUGH - + Do you have a chronic cough, sore throat, or difficulty swallowing? Chronic cough and similar throat issues are highly correlated with Sleep Apnea and Gastroesophageal Reflux Disease (GERD), which often occur together. It’s reported that 80% of the 60 million Americans who’ve been diagnosed with GERD report worse symptoms at night, and 3 in 4 wake up rou- tinely from sleep.

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10. DEVIATED SEPTUM - + 4. 40% TONGUE RESTRICTION Are you aware of having a deviated septum (Tongue-tie) or nasal deformity or damage? A normal range of free tongue movement A deviated septum can be present from is greater than 16 mm.9 Ankyloglossia can be birth, be the result of poor maxillary develop- classified into 4 classes based on Kotlow’s as- ment, or can occur after injury. It can contrib- sessment(10) as follows; ute to difficulty breathing through the nose, • Class I: Mild ankyloglossia: nasal congestion, recurrent sinus infections, 12 to 16 mm, , difficulty sleeping, snoring, sleep • Class II: Moderate ankylo- apnea, headaches and post-nasal drip. glossia: 8 to 11 mm, Clinical Evaluation • Class III: Severe ankyloglos- 1. Neck Circumference Clinical Evaluation sia: 3 to 7 mm, > 16" Women, > 17" Men 1. NECK CIRCUMFERENCE • Class IV: Complete ankylo- 2. Mallampati >2 > 16” Women, > 17” Men glossia: Less than 3 mm. 3. Scalloped Tongue It has been demonstrated, through sever- Class III and IV tongue-tie cate- 4. 40% Tongue Restriction/ al studies, that enlarged necks are associat- gory should be given special con- Tongue-tie ed with increased soft tissue volume in the sideration because they severely 5. Nasal Stenosis throat area.5 Neck size can be associated restrict the tongue’s movement. 6. Skeletal Profile with being overweight, same as waist size. Restrictions include limitations of movement protrusively, laterally 2. MALLAMPATI > 2 and vertically. The Mallampati Score6 comprises a visual One screening evaluation involves: assessment of the distance from the tongue 1. Have the patient open their mouth as base to the roof of the mouth, and therefore wide as possible. Normal maximum the amount of space for an adequate airway. opening is 40-50 mm. The score is assessed by asking the patient, in 2. While maximally open, raise the tip a sitting posture, to open the mouth and pro- of the tongue, attempting to touch trude the tongue as much as possible, rating the incisive papilla behind the upper in 4 classes. central incisors. Successful touching • Class 1: Soft palate, uvula, fauces, represents “normal” tongue mobility. pillars visible. Tongue restrictions can be visualized • Class 2: Soft palate, uvula, fauces as a percentage of movement from visible. rest to full extension towards the in- • Class 3: Soft palate, base of uvula cisive papillae. 40% restriction or visible. greater often has significant clinical • Class 4: Only hard palate visible. implications. A higher Mallampati score is a predictor for risk of OSA and can be a helpful screening 5. NASAL STENOSIS tool during the clinical examination. How- A simple observation can be made by ever, its role in predicting severity of OSA having the patient breathe in and out through remains doubtful and needs further study.7 It the nose. Does the nostril on one or both should be noted that some individuals with a sides collapse during nasal breathing? This Mallampati 1 or 2 may have serious airway provides a visible indicator of nasal airway compromise. collapse or obstruction. It would be common that these patients struggle with upper airway 3. SCALLOPED TONGUE resistance and default to mouth breathing. The presence of tongue scalloping has shown a high correlation for abnormal AHI, 6. SKELETAL PROFILE and nocturnal desaturation. The presence Maxillary and/or mandibular skeletal and severity of tongue scalloping has shown underdevelopment can compromise airway a positive correlation with increasing Malla- volume.11 Arnett’s True Vertical12 is a useful mpati. In high-risk patients, tongue scallop- assessment for mandibular retrusion, maxil- ing has been found to be predictive of sleep lary retrusion, and bimaxillary (maxillo-man- pathology. Tongue scalloping is a useful clin- dibular) retrusion, by observing the patient’s ical indicator.8 profile, facing to the right.

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A line dropped vertically down from the TESTING: HOME SLEEP TESTING (HST) nose-lip intersection (SN) relates ideally to Home sleep testing has become a stan- the fully developed lower face when: dard for evaluation and diagnosis of sleep Upper Lip = 2-5 mm in front of the line disorders in recent years. Though less infor- Lower Lip = 0-3 mm in front of the line mation is gathered relative to polysomnog- Chin Point = -4-0 mm behind the line. raphy (PSG) studies, the accuracy appears Measurements less than these ranges can comparable15. Most home testing recorders implicate craniofacial, mid-face underdevel- can track time of the test period, but not opment, with increased risk for airway com- sleep time, which requires EEG signals. They promise. also gather data about oximetry, pulse rate, sleep position, apnea & hypopnea episodes, Screening & Testing snoring, and chest effort. The reports include SCREENING: HIGH RESOLUTION PULSE an AHI. A new term, REI, or Respiratory OXIMETRY (HRPO) Event Index, has been adopted by the Ameri- Overnight HRPO monitors two signifi- can Academy of Sleep Medicine to designate cant factors that relate to healthy or dysfunc- results from testing when true sleep time is tional breathing. not measured. There is a lot of other data on even a ‘simple’ test that provides insight to 1. SO2 – Oxygen saturation is the fraction of oxygen-saturated hemoglobin rela- the patient’s sleep. tive to total hemoglobin (unsaturated Note: Dentists are not qualified or - li + saturated) in the blood. The human censed to interpret sleep apnea. HST should Screening & body requires and regulates a very pre- be interpreted by a Board Certified Sleep cise and specific balance of oxygen in Physician. Many HST manufacturers provide Testing the blood. Normal blood oxygen lev- an interpretation service. Dentists are the • Screening: High els in humans are considered 95–100 ideal health professionals to screen patients Resolution Pulse percent. If the level is below 90 per- and gather studies for potential airway dis- Oximetry (HRPO) cent, it is considered low (). orders. When HST reveals significant signs • Testing: Home Sleep Blood oxygen levels below 80 percent of breathing dysfunction and elevated AHI, Testing (HST) may compromise organ function, such referral for an overnight laboratory PSG will as the brain and heart. Continued low analyze important additional information oxygen levels may lead to respiratory such as EEG and CSA. The results may sig- or cardiac arrest.13 nificantly altar the treatment plan. 2. Pulse Rate – During non-REM sleep, Dr. Tom Colquitt, Past President of the the pulse rate tends to slow down 14- American Academy of Restorative Dentistry 24 beats per minute, compared with (AARD), addressed the 2016 session of that wakefulness. The average heart rate Academy with the following critical state- range during all 3 stages of non-REM ment: “Other than emergency care, the first sleep is between 60-100. Some indi- procedure performed by every dentist, for ev- viduals may have a normally slower or ery patient, of any age should be a proper air- faster heart rate range. Non-REM rep- way examination and evaluation of breathing resents roughly 75-80% of time asleep. function.” REM sleep includes periods of dream- Airway and breathing disorders are be- ing and increased heart rate, with coming an increasing area of emphasis in more variability. REM is often concen- Dentistry. trated in the last few hours of sleep. Form follows function. HRPO can screen for disordered Properly functioning nasal breathing, breathing during sleep by observing tongue posture, and swallowing patterns greatly influence a properly formed dental the recorded “Delta” of both SO2 and Pulse Rate. Delta involves the differ- occlusion. On the contrary, dysfunctional ence between high and low values. mouth breathing, tongue posture, and swal- lowing patterns greatly influence an improp- Large swings in both SO2 and Pulse Rate over short intervals, on multiple erly formed dental malocclusion. This may occasions throughout sleep, may indi- include TMD symptoms, clenching, brux- cate a breathing disorder. Precise in- ism, tooth abrasion and erosion, headaches, terpretation is often difficult.14 GERD and broad systemic effects.

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Brent Bauer M.D., Internist and Editorial Board member for the Mayo Clinic Health Properly functioning nasal Letter wrote an article entitled, Buzzed on Inflammation.16 “Inflammation is the new breathing, tongue posture, and medical buzzword. It seems as though every- swallowing patterns greatly one is talking about it, especially the fact that inflammation appears to play a role in many influence a properly formed chronic diseases.” One of the most important dental occlusion. On the sources of systemic inflammation is related to breathing dysfunction. For example, OSA contrary, dysfunctional mouth may activate the sympathetic/adrenomedul- breathing, tongue posture, lary and the hypothalamic-pituitary-adrenal (HPA) axis limbs of the neurologic stress sys- and swallowing patterns tem.17 Nocturnal micro-arousals and awak- greatly influence an enings are associated with chronic cortisol release. Over days, months and years this can improperly formed influence a number of inflammatory related dental malocclusion. problems including insulin resistance and diabetes; dysregulation of the hunger hor- mones, leptin and ghrelin, leading to weight gain and , and OSA directly affects the vascular endothelium by promoting inflam- mation and oxidative stress while decreasing NO availability and repair capacity.18 The demands of clinical practice are ever-increasing. Dentists must be aware of more health concerns every day. Patients are direction. You can be ready to help them by asking about airway because they read about using the provided Checklist to identify air- health effects of sleep related breathing dis- way and breathing related disorders in your orders and look to their trusted dentist for dental practice.

1. ADA Adopts Policy on Dentistry’s Role in Treating Obstructive Sleep Apnea, Similar Disorders. ada.org October 23, 2017 News Releases 2. The Oxygen Advantage. Patrick McKeown 2015, William Morrow/Harper Collins Publisher 3. Implications of mouth breathing on the pulmonary function and respiratory muscles. Vern, H Antunes, A Milanesi J et.al Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016 4. A frequent phenotype for pediatric sleep apnea: short lingual frenulum. Guilleminault C, Huseni S, Lo L ERJ Open Research 2016 2: 00043-2016 5. Which Oropharyngeal Factors Are Significant Risk Factors for Obstructive Sleep Apnea? An Age-Matched Study and Dentist Perspectives Nat Sci Sleep. 2016; 8: 215–219 6. Mallampati Score, Wikipedia 7. Importance of Mallampati score as an independent predictor of obstructive sleep apnea. Kanwar M, Jha R European Respiratory Journal 2012 40: P3183; 8. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Weiss TM, Atanasov S, Calhoun KH Otolaryngol Head Neck Surg. 2005 Dec;133(6):966-71. 9. Ankyloglossia and its management. Chaubal T, Dixit M J Indian Soc Periodontol. 2011 Jul-Sep; 15(3): 270–272. 10. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Kotlow LA. Quintessence Intl. 1999;30:259–62. 11. Impact of Mandibular Distraction Osteogenesis on the Oropharyngeal Airway in Adult Patients with Obstructive Sleep Apnea Secondary to Retroglossal . Ramanathan Manikandhan, Ganugapanta Lakshminarayana, Pendem Sneha, Parameshwaran Ananthnarayanan, Jayakumar Naveen, and Hermann F. Sailer. J Maxillofac Oral Surg. 2014 Jun; 13(2): 92–98. 12. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. William Arnett, DDS, FACD, Jeffrey S. Jelic, DMD, MD, Jone Kim, DDS, MS, David R. Cummings, DDS, Anne Beress, DMD, MS, C. MacDonald Worley, Jr, DMD, MD, BS, Bill Chung, DDS, Robert Bergman, DDS, MSh. American Journal of Orthodontics and Dentofacial Orthopedics Volume 116, Number 3 September 1999 13. Oxygen saturation(medicine) Wikipedia 14. Examination of tracings to detect obstructive sleep apnea in patients with advanced chronic obstructive pulmonary disease. Adrienne S Scott, Marcel A Baltzan, and Norman Wolkove Can Respir J. 2014 May-Jun; 21(3): 171–175 15. Diagnostic accuracy of level 3 portable sleep tests versus level 1 for sleep-disordered breathing: a systematic review and meta-analysis Mohamed El Shayeb, MD MSc, Leigh-Ann Topfer, MLS, Tania Stafinski, PhD, Lawrence Pawluk, MD, Devidas Menon, PhD. CMAJ. 2014 Jan 7; 186(1) 16. “Buzzed on inflammation.” Brent Bauer MD, Mayo Clinic Health Letter. N.p., n.d. Web. 16 Sept. 2014. http://health letter.mayoclinic.com/editorial/editorial.cfm/i/163/t/Buzzedon inflammation 17. Buckley TM, Schatzberg AF. On the interactions of the hypothalamic-pituitary-adrenal (HPA) axis and sleep: normal HPA axis activity and circadian rhythm, exemplary sleep disorders. J Clin Endocrinol Metab. 2005;90:3106–3114. 18. Inflammation, Oxidative Stress, and Repair Capacity of the Vascular Endothelium in Obstructive Sleep Apnea. Sanja Jelic, MD, Margherita Padeletti, MD, Steven M. Kawut, MD, MS, Christopher Higgins, MD, Stephen M. Canfield, MD, Duygu Onat, PhD, Paolo C. Colombo, MD, Robert C. Basner, MD, Phillip Factor, DO, and Thierry H. LeJemtel, MD. Circulation. 2008 Apr 29; 117(17): 2270–2278.

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A Checklist for Evaluation of Potential Airway & Breathing Disorders by DeWitt C. Wilkerson, DMD

1. Mouthbreathing is considered dysfunctional b. Is less common at higher altitudes due to c. It is a major clue for airway behavior during

breathing because ______. relatively larger percentage of CO2 in the air sleep a. It interferes with swallowing c. Primarily is a central nervous system disorder d. Because chronic hyperactivity of neck mus- b. It could lead to inflammation in the throat d. Is more readily observed by bed partners cles can influence TMD c. Passing air over the tonsils produces excess due to lack of breathing effort nitric oxide 8. Scalloped Tongue ______. d. Lip dryness results in increased chance of 5. Sleep Quality may be assessed by questioning a. Is pathognomonic for bruxism infection ______. b. Means there is insufficient room for the a. Whether the patient moves frequently tongue within the dental arches 2. Using a checklist in your office for assessing during sleep c. Is positively correlated with a crowded oro- airway ______. b. If dreams can be recalled pharynx a. Enables your office to implement the ADA c. How many hours the patient is able to stay d. Could be any or all of these Policy Statement on Sleep Related Breath- asleep d. How often they have to use the bathroom 9. Arnett’s True Vertical ______. ing Disorders during the night a. Requires a cephalometric tracing to evaluate b. Provides you an opportunity to evaluate b. Is a measurement of the quality of prior or- one of the key parameters of health 6. Nasal Breathing ______. thodontic therapy c. Distinguishes your office from those who a. Nasal patency is best left to the otolaryngol- c. Is a useful tool to assess how skeletal devel- only provide typical dental services ogists to address opment relates to airway volume d. All of the above b. Is part of any airway assessment by a trained d. Is used to avoid path of insertion problems provider when incisors are flared facially 3. During sleep apnea events ______. c. Contributes to sleep apnea because it re- a. Cortisol is released into the bloodstream quires more work than mouth breathing 10. Respiratory Event Index ______. b. Breathing can stop for 5 seconds or longer d. Can be improved by using EPAP devices a. Is used in sleep labs to correlate obstructive c. Leptin increases the heart rate and central apnea with brain responses d. The body is more likely to develop central 7. Dentists should evaluate their patient’s neck b. Is more accurate than Apnea Hypopnea In- sleep apnea posture ______. dex in assessing airway problems a. So they can properly adjust the dental chair c. Is made up of snoring sounds plus body 4. Central Sleep Apnea ______. for comfortable procedures movements divided by test time a. Is triggered by many of the same problems b. Because it influences how far forward the d. Is a new term from American Academy of that create obstructive sleep apnea jaw can go with an oral appliance Sleep Medicine for use with HST

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