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A Checklist for Evaluation of Potential Airway & Breathing Disorders

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A Checklist for Evaluation of Potential Airway & Breathing Disorders CONTINUING education 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 signs and symptoms of dys- functional breathing and sleep 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 Apnea 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. 20 DSP | Summer 2018 CONTINUING education With the endorsement of the ADA, well. Approximately one in three snorers also screening and treating sleep-related breath- suffers from obstructive sleep apnea. 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) Obstructive Sleep Apnea 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 Mouth breathing 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, choking 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 Cough 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. Central Sleep Apnea (CSA) is a CNS dis- 2. SNORE - + order in which the respiratory center in the Are you aware of snoring 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 Sleep Medicine, 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. DentalSleepPractice.com 21 CONTINUING education 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. 22 DSP | Summer 2018 CONTINUING education 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, nosebleeds, 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.
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