Sleep Apnea and Bruxism Habitual Snoring
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CAPD/ACDP Montreal 2014‐09‐13 Sleep disordered breathing (SDB) Occasional snoring Sleep apnea and bruxism Habitual snoring CAPD-ACDP 2014 Annual Meeting, Montreal Upper airway resistance syndrome Sleep apnea Increasing upper airway collapsibility airway upper Increasing Andrée Montpetit, DMD, MSc, RCDC Nelly Huynh, PhD Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation [email protected] [email protected] Snoring vibration of respiratory structures and the resulting sound, due to obstructed air movement while breathing during sleep. Obstructive Sleep Apnea (OSA) « characterized by repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction occurring during sleep. These events often result in reductions in blood oxygen saturation and are usually terminated by brief arousals from sleep. » Central Sleep Apnea « characterized on the polysomnogram by recurrent cessation off respiration during sleep with the apnea having no associated ventilatory effort. » Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Sleep study Epidemiology • Snoring Mild Moderate Severe • 3% to 12% 25% 5 to 15 events/hr 15 to 30 events/hr more than 30 events/hr Habitual snoring ??? • Sleep apnea AHI ≥ 10 and over is treated if SLEEPINESS and HBP • 1% to 10% 2% Huynh et al. 2012 AJODO Mild Moderate Severe 1 to 5 events/hr 5 to 10 events/hr more than 10 events/hr 34% mouth breathers Habitual snoring abnormal Clinically significant ≥5/hr due to study on elevated BP [Bixler 2008] • Prevalence peak between 2-8 y.o. [Fujioka 1979, Jeans 1981, Sahin 2009] Dayyat 2007; AASM 2005 Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation 1 CAPD/ACDP Montreal 2014‐09‐13 Seasonal incidence Consequences As early as perinatal period • Woman with OSA have increased risks for: • 1.8% for low birth weight • 2.3% for preterm birth • 1.3% for small size for gestational age • 1.7% for cesarian section • 1.6% for preeclampsia/eclampsia Chen et al. 2012 Am J Obstet Gynecol Walter et al. 2013 Arch Dis Child Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Consequences Can SDB grow an ADHD child? Cardiovascular Metabolism Growth Cognition Hypoxic stress Growth delay Controversial ↓ ↑sympathetic activation Growth catch-up Execute functions ↓ after T&A and behavior Insulin resistance (Type 2 Diabetes) ↑ ↑nocturnal cortisol Following treatment: ↑ Hypersomnolence Constantin et al., 2014 Behav Sleep Med ↓ TNF-α [Montgomery-Downs 2010; Ungkanont 2006; Liu 2005, (inflammatory Nimubona 2000; • By 4 y.o., children with mouthbreathing, snoring and/or witnessed apnea were cytokines) Trachtenbard 1998; [Lewin 2002, O’Brien 2004, Commare 1993; Breton Beebe 2004, Halbower 2006, 20-60% more likely to exhibit behavioral difficulties consistent with clinical dx. 1993; Stradling 1990] Honaker 2009, Calhoun 2009, [Kiris 2010; Aydogan 2007; Kohler 2009, Sahin 2009, [Gozal 2010] Bar 1999] Ting 2010] • By 7 y.o., they were 40-100% more likely. Bonnuck et al., 2012 Pediatr Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Consequence – mortality in adults Risk factors Children Adults Although there is no 1. Nasal obstruction 1. Obesity available data in children, 2. Skeletal morphology 2. Nasal obstruction untreated apnea leads to 3. Soft tissues 3. Skeletal morphology greater mortality in 4. Obesity 4. Soft tissues adults. 5. Familial predisposition 5. Familial predisposition Growth Aging He et al., 1988 Chest Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation 2 CAPD/ACDP Montreal 2014‐09‐13 Nasal obstruction Risk factors Children Adults • Seasonal allergic rhinitis • Deviated septum 1. Nasal obstruction 1. Obesity • Hypertrophy of turbinates 2. Skeletal morphology 2. Nasal obstruction 3. Soft tissues 3. Skeletal morphology 4. Obesity 4. Soft tissues 5. Familial predisposition 5. Familial predisposition Growth Aging Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s rôleClinicalTreatments Evaluation PANIC study PANIC study • 6-8 years old with • 6-8 years old with and without SDB and without SDB • Questionnaires • Questionnaires • Abnormal palatal morphology (Mallampati III or IV) • Thick neck • Adipose tissue under the chin • Abnormal craniofacial morphology, but not excess • Cross bite body fat, is associated with an increased risk of having • Open bite SDB in 6-8-year-old children • Convex facial profile • Increased lower facial height • Mandibular retrusion • Tonsilar hypertrophy Ikavalko et al., 2012 Ikavalko et al., 2012 Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Craniofacial morphology Craniofacial morphologies in children with OSA • Strong association between OSA and congenital craniofacial malformations Risk factors Authors Studies • Mandibular hypoplasia Marino 21 OSA pts (mean age 4.5 y.o.) • Pierre-Robin 2009 Ceph Long and narrow face • Prader-Willi • Treacher-Collins Pirila- 41 OSA pts (mean age 7.2 y.o.) vs Narrow width • Marfant Parkkinen 41 controls 2009 Dental casts (high arch palate, narrow maxillary) Pirila- • Maxillary hypoplasia 70 snorers/symptomatic OSA pts, Parkkinen • Down syndrome 70 controls (mean age 7.2 y.o.) • Cleft palate 2010 Mandibular • Apert, Crouzon or Pfeiffer syndromes Tsuda 173 children (20% strong snorers) retrognatia 2010 OSA-18 and ceph Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation 3 CAPD/ACDP Montreal 2014‐09‐13 Predisposing factors/risks Risk factors Children Adults 1. Nasal obstruction 1. Obesity 2. Skeletal morphology 2. Nasal obstruction Sleep Craniofacial disordered 3. Soft tissues 3. Skeletal morphology imbalances breathing 4. Obesity 4. Soft tissues 5. Familial predisposition 5. Familial predisposition Growth Aging Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Soft tissues - airway Age – tonsils and adenoids Controls OSA • Narrowest at A+T • In snoring children: T&A hypertrophy persists A – adenoids; T – tonsils; A+T – overlap; E – epiglottis Arens et al. 2003 Papaioannou et al. 2013 J Pediatr MécanismesMechanisms RisquesRisksSymptomsSymptômesSymptomsTreatmentsTraitementsScreeningRoleRôle of duDentist dentisteDentist’s roleClinicalÉvaluationTreatments Evaluation clinique MécanismesMechanisms RisquesRisksSymptomsSymptômesSymptomsTreatmentsTraitementsScreeningRoleRôle of duDentist dentisteDentist’s roleClinicalÉvaluationTreatments Evaluation clinique Soft tissues Macroglossy • Tonsils • Often in association with a syndrome • classification: 4 CAPD/ACDP Montreal 2014‐09‐13 Soft tissues Airway obstruction from soft tissues • Long soft palate Risk factors Obesity Children Adults • Obese children have a (4.5x) increased risk of developing obstructive sleep apnea [Redline 1999] 1. Nasal obstruction 1. Obesity 2. Skeletal morphology 2. Nasal obstruction • Incidence of SDB: 3. 3. Soft tissues Skeletal morphology • Obese children– 46% [Marcus 1996] 4. Obesity 4. Soft tissues • Morbidly obese children– 55% [Kalra 2005] 5. Familial predisposition 5. Familial predisposition • Possible causes: • Adipose tissue deposited in pharyngeal Growth Aging area (fat pads) [Shelton 1993, Schwab 2003] Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation MécanismesMechanisms• TissusRisquesRisks SymptomsadipeuxSymptômesSymptomsTreatments TraitementsviscéralScreeningRole Rôle[Vgontzas of duDentist dentisteDentist’s 2008, Makino roleClinicalÉvaluation 2009] Treatments Evaluation clinique Risk factors Breastfeeding and snoring Children Adults 1. Nasal obstruction 1. Obesity 2. Skeletal morphology 2. Nasal obstruction 3. Soft tissues 3. Skeletal morphology 4. Obesity 4. Soft tissues 5. Familial predisposition 5. Familial predisposition • Breastfeeding for at least one month reduced the risk of parent reported snoring and witnessed apneas. Growth Aging • In this study, no children breastfed more than 3 month had witnessed apneas at age 8. Brew et al. 2014 PLOS one Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s roleClinicalTreatments Evaluation Mechanisms RisksSymptomsSymptomsTreatmentsScreeningRole of DentistDentist’s