CAPD/ACDP Montreal 2014 09 13 · PDF file2% Huynh et al. 2012 AJODO ... mandibular rotation,...

CAPD/ACDP Montreal 2014‐09‐13

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Sleep apnea and bruxismCAPD-ACDP 2014 Annual Meeting, Montreal

A n d r é e M o n t p e t i t , D M D , M S c , R C D C N e l l y H u y n h , P h D a n d r e e . m o n t p e t i t @ u m o n t r e a l . c a n e l l y . h u y n h @ u m o n t r e a l . c a

Sleep disordered breathing (SDB)

Occasional snoring

Habitual snoring

Upper airway resistance syndrome

Sleepapnea

Symptoms Treatments Role of Dentist Clinical Evaluation

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Symptoms Screening Dentist’s role TreatmentsRisksMechanisms

Obstructive Sleep Apnea (OSA)« characterized by repetitive episodes of complete(apnea) or partial (hypopnea) upper airwayobstruction occurring during sleep. These eventsoften result in reductions in blood oxygen saturation and are usually terminated by brief arousals fromsleep. »

Central Sleep Apnea« characterized on the polysomnogram by recurrentcessation off respiration during sleep with the apneahaving no associated ventilatory effort. »

Snoringvibration of respiratory structures and the resulting sound, due to obstructed air movement while breathing during sleep.

Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

Sleep study

Mild1 to 5 events/hr

Moderate5 to 10 events/hr

Severemore than 10 events/hr

Mild5 to 15 events/hr

Moderate15 to 30 events/hr

Severemore than 30 events/hr

Habitual snoring abnormalClinically significant ≥5/hr due to study on elevated BP [Bixler 2008]

Habitual snoring ???AHI ≥ 10 and over is treated if SLEEPINESS and HBP

Dayyat 2007; AASM 2005

Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

• Snoring• 3% to 12%

• Sleep apnea• 1% to 10%

• Prevalence peak between 2-8 y.o.[Fujioka 1979, Jeans 1981, Sahin 2009]

25%

2% Huynh et al. 2012 AJODO

34% mouth breathers

Epidemiology



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Seasonal incidence

Walter et al. 2013 Arch Dis Child


ConsequencesAs 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


Consequences

Following treatment:

↓ TNF-α(inflammatorycytokines)

[Gozal 2010]

Cardiovascular Metabolism Growth Cognition

Hypoxic stress↓

↑sympathetic activation

↓Insulin resistance (Type 2 Diabetes)

↑↑nocturnal cortisol

↑Hypersomnolence


Growth delay

Growth catch-up after T&A

[Montgomery-Downs 2010; Ungkanont 2006; Liu 2005, Nimubona 2000; Trachtenbard 1998; Commare 1993; Breton 1993; Stradling 1990][Kiris 2010; Aydogan 2007; Bar 1999]

Controversial

Execute functionsand behavior

[Lewin 2002, O’Brien 2004, Beebe 2004, Halbower 2006, Honaker 2009, Calhoun 2009, Kohler 2009, Sahin 2009, Ting 2010]

Can SDB grow an ADHD child?

Constantin et al., 2014 Behav Sleep Med

• By 4 y.o., children with mouthbreathing, snoring and/or witnessed apnea were 20-60% more likely to exhibit behavioral difficulties consistent with clinical dx.

• By 7 y.o., they were 40-100% more likely.Bonnuck et al., 2012 Pediatr


Consequence – mortality in adults

Although there is no available data in children, untreated apnea leads to greater mortality in adults.

He et al., 1988 Chest


Risk factors

Children

1. Nasal obstruction2. Skeletal morphology3. Soft tissues4. Obesity5. Familial predisposition

Growth

Adults

1. Obesity2. Nasal obstruction3. Skeletal morphology4. Soft tissues5. Familial predisposition

Aging



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Nasal obstruction

• Seasonal allergic rhinitis• Deviated septum• Hypertrophy of turbinates


Risk factors

Children


Growth

Adults


Aging

Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s rôle TreatmentsRisksMechanisms

PANIC study• 6-8 years old with

and without SDB• Questionnaires

Ikavalko et al., 2012


• Abnormal palatal morphology (Mallampati III or IV)• Thick neck• Adipose tissue under the chin

• Cross bite• Open bite• Convex facial profile• Increased lower facial height• Mandibular retrusion• Tonsilar hypertrophy

PANIC study• 6-8 years old with

and without SDB• Questionnaires

Ikavalko et al., 2012


• Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6-8-year-old children

Craniofacial morphologies• Strong association between OSA and congenital craniofacial malformations

• Mandibular hypoplasia• Pierre-Robin• Prader-Willi• Treacher-Collins• Marfant

• Maxillary hypoplasia• Down syndrome• Cleft palate• Apert, Crouzon or Pfeiffer syndromes


Risk factors

Craniofacial morphology in children with OSA

Long and narrow face

Narrow width (high arch palate, narrow maxillary)

Mandibular retrognatia

Authors Studies

Marino 2009

21 OSA pts (mean age 4.5 y.o.)Ceph

Pirila-Parkkinen

2009

41 OSA pts (mean age 7.2 y.o.) vs 41 controls

Dental casts

Pirila-Parkkinen

2010

70 snorers/symptomatic OSA pts, 70 controls (mean age 7.2 y.o.)

Tsuda2010

173 children (20% strong snorers)OSA-18 and ceph



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Predisposing factors/risks

Sleepdisordered breathing

Craniofacial imbalances


Risk factors

Children


Growth

Adults


Aging


Arens et al. 2003

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

Soft tissues - airway

Controls OSA

• Narrowest at A+T

A – adenoids; T – tonsils; A+T – overlap; E – epiglottis

Age – tonsils and adenoids

• In snoring children: T&A hypertrophy persistsPapaioannou et al. 2013 J Pediatr


Soft tissues• Tonsils

• classification:

Macroglossy• Often in association with a syndrome


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Soft tissues• Long soft palate

Airway obstruction from soft tissues

Risk factors

Children


Growth

Adults


Aging


Obesity• Obese children have a (4.5x) increased risk

of developing obstructive sleep apnea [Redline 1999]

• Incidence of SDB:• Obese children– 46% [Marcus 1996]

• Morbidly obese children– 55% [Kalra 2005]

• Possible causes:• Adipose tissue deposited in pharyngeal

area (fat pads) [Shelton 1993, Schwab 2003]

• Tissus adipeux viscéral [Vgontzas 2008, Makino 2009]Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

Risk factors

Children


Growth

Adults


Aging


Breastfeeding and snoring

Brew et al. 2014 PLOS one


• Breastfeeding for at least one month reduced the risk of parent reported snoring and witnessed apneas.

• In this study, no children breastfed more than 3 month had witnessed apneas at age 8.


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Mouth breathing

• Often associated with upper airway obstruction• Tonsils & Adenoids hypertrophy• Nasal congestion

• Associated with habitual snoring

• If present during growth, it can alter the development of the canial and jaw morphology.


Growth


Septal deviation/chronic rhinitis

Nasal airway resistance

Mouth breathing

Alters position of tongue (stays low)

Deep and narrow palate

Mouth breathing is associated with a clockwise mandibular rotation, increased lower face hight, cl.IImalocclusions and high arch palates.

Harari 2010, D’Ascanio 2010, Peltomäki 2007, Mattar 2004

Sleep in OSA children• Pre-school age children’s sleep is not affected as much as school age

children. • But they have more central apeas

Walter et al. 2012 Sleep Med


Daytime signs and symptoms• Hyperactivity• Behaviour problems• Attention deficit• Sleepiness


Nightime signs and symptoms• Agitated sleep• Sweating• Nocturia / enuresis• Nightmares• Bruxism

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationScreening Dentist’s role TreatmentsRisks SymptomsMechanisms


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Bruxism

“Repetitive jaw-muscle activity characterized by clenching or

grinding of the teeth and/or by bracing or thrusting of the

mandible”

1997AASM published ICSD-1

Classified as parasomnia

2005AASM published ICSD-2

Classified as movement disorder

2013International consensus

(and ICSD-3)

Bruxism - prevalence

0

5

10

15

20

25

30

35

40

45

< 12 y.o. 18-29 y.o. Adults > 60 y.o.

Sleep bruxism is the 3rd most frequent parasomnia [Ohayon 2001]

< 40%

13% 3%6-8%

Reding 1966; Goulet 1992; Lavigne 1994; Ohayon 2001; Laberge 2000; Cheifetz 2005

Bruxism

Qualitative + quantitative

Questionnaire + PSG 5.5%

Sleep recording (complete PSG)

Prevalence with PSG 7.4%

“ground, clenched, tapped or made noise with their teeth during sleep or any time in their life” (n=1019)

Prevalence with questionnaires 12.5%

Maluly et al., 2013

Bruxism – parental reports• Rhythmic masticatory activity (quantitative) associated to parental reports (qualitative):

Bruxism – risk factors

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Self-reported Bruxism

Moderate daytime fatigue

OR 1.3

Snoring (OR 1.2)

Sleep apnea

(OR 1.8)

Daily alcohol

(OR 1.5)Daily caffeine

(OR 1.4)

Nicotine

(OR 1.3)

Stress/anxiety

(OR 1.3)

Ohayon et al., 2001

Bruxism and OSA• In patients with bruxism:

• 4.8% in bruxers vs. 1.4% in non-bruxers• Apnea 2-3x more frequent in bruxers• Reduction of bruxism with mandibular advancement appliances

[Landy 2006; Carra 2013]

• In patients with OSA:• 50% of children with OSA will develop bruxism [Lamberg 2008]

• Bruxism decreases or disappears in 75% of children followingadenotonsillectomy [DiFrancesco 2004]

Sleep bruxism

OSABruxismmay help

to re-establishairwayopening


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Sleep testing

• Type I

• Type II• Type III• Type IV

In-lab attended

Unattended(usually at home)

type I – in-lab attended polysomnography[EEG, EOG, EMG, EKG, breathing, oxymetry, audio-video]

Info derived:• Sleep• EEG arousals• Hypoxia• Respiratory

events• EKG arrhythmia• Leg movements

Symptoms Treatments Role of Dentist Clinical EvaluationScreening Dentist’s role TreatmentsRisks SymptomsMechanisms

type IV – limited home polysomnography[3 channels: breathing (efforts), oxymetry]

Info derived:

• Hypoxia as a screen for sleep apnea

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationScreening Dentist’s role TreatmentsRisks SymptomsMechanisms

• Screening and referral to pediatric sleep specialist or ENT

• Provide craniofacial assessment and growth follow-up

• Treat or refer to address craniofacial anomalies

ROLE OF THE DENTIST(pedodontist/orthodontist)


Role



Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

Diagnostic by a sleep physician• Medical history

• Physical exam

• Sleep study



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Medical history

• Family – genetic predisposition

• Sleep bruxism was more frequently observed in monozygotic twins [Lindqvist 1974; Hublin 1998]

• Increased sibling risk of OSA in children, which may be due to heritable genes and/or shared environment [Friberg 2009]

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms Symptômes Traitements Rôle du dentiste Évaluation clinique

Lifestyle and/orbehavior modification

• Weight loss• Avoid alcohol, sedatives and hypnotics• Positional therapy

Positive airwaypressure

• Continuous positive airway pressure (CPAP)• Auto-titrating CPAP• Bi-level PAP

Medication • Nasal corticosteroids• Leukotriene receptor antagonist

Oral devices• Tongue-retaining device• Palatal-lifting device• Mandibular advancing device

Surgery

• Nasal surgery• Tonsillectomy• Uvulopalatopharyngoplasty (UPPP)• Lingualplasty• Genioglossus and hyoid advancement• Sliding genioplasty• Maxillo-mandibular advancement osteotomy (MMA)• Laser-assisted uvulopalatoplasty (LAUP)• Radiofrequency volumetric tissue reduction• Tracheostomy• Bariatric surgery

Dento-facial orthopedics

• Rapid Maxillary Expansion• Surgically-Assisted Rapid Maxillary Expansion• Myofunctional Device (mandibular)

RisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

If left untreated?Author Study Development

Marcus 1998N=20 (2-15y.o.) Primary snoring1-3 yrs F/U with PSG

•Majority do not develop OSA•10% have moderate OSA after 3 yrs

Topol 2001N=13 childrenPrimary snoring3 yrs F/U with PSG

•No difference between patients and controls•Only youngest child developed OSA

Anuntaseree 2005

N=755 children(questionnaires)N=7 children (PSG)Snoring/OSA3 yrs F/U

•65% of snorers stopped•9% of children developed OSA

Li 2010N=45 (6-13y.o.) Mild OSA (1-5/hr)2 yrs F/U with PSG

•Moderate improvement•29% aggravate (male, regular snoring, hypertrophy of tonsils, ↑waist circumference)

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes Symptoms Treatments Role of Dentist Clinical EvaluationSymptoms Screening Dentist’s role TreatmentsRisksMechanisms

9 to 29% of children with SDBwill continue/aggravate

Weight loss (obesity)• With a loss of 32% of their BMI, a success rate of 71%

• 12 of 49 patients (24%) have persistent OSA even following weight loss

Symptômes Traitements Rôle du dentiste Évaluation cliniqueRisquesMécanismes

Van Hoorenbeeck et al., 2012


Sleeping position• In 3-5y.o., no difference in AHI associated with

position

• In 6-10y.o. and 11-13y.o., side-sleeping is associated with a decreased AHI vs. on their back

Zhang et al., 2007


Nasal corticosteroids• 6 weeks• 25 children between 1 and 10 y.o.


Brouillette et al., 2001



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Montelukast• Singulair : leukotriene receptor antagonist for asthma

and seasonal allergies

• 4-5 mg/d for 12 weeks


Goldbart et al., 2012


First-line treatments1. Adenotonsillectomy 2. Positive airway pressure

2. Maxillary expansion


AHI <1 post-op60% success

AHI <5 post-op66% success

Adenotonsillectomy

20 to 40% cases are not resolved

Symptômes Traitements Rôle du dentiste Évaluation clinique

Adenotonsillectomy,is curative in approximately 80% of

pediatric cases of pediatric OSA

RisquesMécanismes

Friedman et al., 2009(meta-analysis of 23 studies)

Carvalho et al., 2012


Adenotonsillectomy• Hypoxemia (4 studies)

• Improvement of nocturnal oxygen saturation

• Blood pressure (3 studies)• Mixed results, although increased BP associated with recurrent OSA

• Cardiovascular control (4 studies)• Decrease in sympathetic activity

• Inflammation and endothelial function (8 studies)• C-reative protein (marker of inflammation) decreased• Altered endothelial function reversed

• Cardiac function and structure (3 studies)• Echocardiographic findings return to normal

Vlahandonis et al., 2013


Persistent apnea

• 13 symptomatic children (27%)

• PSG3 confirms persistent apnea in 9 children (18.4%)

• 70% have adenoids regrowthTagaya et al., 2012


PSG2 post-op

PSG1 pre-op

PSG3 1.5yr F/U

Persistent apnea

• Recurrent SDB is reported in teenagers after over 10 yrs following adenotonsillectomy

Guilleminault et al., 1999; Tasker et al., 2002



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Craniofacial analyses• 20 non-operated children (mdx)

vs. 20 children with adenotonsillectomy

• In children with adenotonsillectomy:• Mandibular posterior position• Backward rotation of the mandible• Rotation postérieure de la mandibule• Class II

• Stenosis/narrowing of the nasopharyngeal airway • Elongated soft palate

high probability of the necessity of adenotonsillectomy when a morphological factor played a major role for OSA

Sato et al., 2012


Positive airway pressure

• Some craniofacial changes

• midface hypoplasia (nasal mask)

• Case-report: CPAP worn between5 to 15 y.o.

* Mostly used in children withcomplicating medical disorders


Li et al., 2000


Orthodontics• Improvement in dento-facial morphology can have a

positive impact on SDB and OSA.

• Maxillary expansion• Role in OSA treatment in children• Widens nasal fossa• Reduces nasal airway resistance

• Orthopaedic maxillary advancement

• Orthopaedic mandibular advancement


4 short term studies+ 1 “long” term study (2 years)

Rapid maxillary expansion

0

2

4

6

8

10

12

14

16

18

20

Baseline AHI Post-expansionAHI

Pirelli 2004

Villa 2007

Miano 2008

Pirelli 2010

Villa 2011

Pirelli P et al., Prog Ortho 2005


Pirelli 2004, Pirelli 2005, Miano 2009, Villa 2007, Villa 2011


Rapid maxillary expansion

Iwasaki et al. 2012 AJODO


Caution with expansion




15 OSA children underwent RPE:• 8 improved• 7 stationary or worsened


Marino et al., 2012 Eur J Paediatr Dent


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More than one treatment?

Group 1

T & A surgery RPE

Group 2 RPE T & A

surgery

31 OSA patients


Guilleminault et al., 2008




Guilleminault et al., 2008


BaselineSevere OSA in both groups

T&A: AHI 4.9RPE: AHI 5.4

Final: AHI 0.9 in both groups



Villa et al., 2013

25 childrenPre-PSG – AHI 17

↓Post-PSG – AHI 1.8

22 childrenPre-PSG – AHI 5

↓Post-PSG – AHI 2.6

5 children Pre-treatment PSG – AHI 10.1

↓Post-treatment PSG – AHI 0.9

Adenotonsillectomy Rapid palatal expansion

Adenotonsillectomy + Rapid palatal expansion

Persistent apnea

Resolved

Functional appliancesStudy Population Methods Results

Cozza 2004 20 OSA patients (4‐8 y.o.) vs 20 CTL

PSG; Cephalometric Rx; MONOBLOC APPLIANCE (for 6 months)

• Differences in craniofacial morphology between groups (at baseline)

• Reduction of AHI in the OSA group following tx with monobloc

• Reduce daytime sleepiness

Villa 2002 32 OSA patients (4‐10 y.o.) with malocclusion

PSG; JAW POSITIONING APPLIANCE (for 6 months)

• Reduction in AHI/resolution of OSA in the treated group compared with non‐treated patients

• Improve snoring, oral breathing, sleep quality, sleepiness, irritability and tiredness

Cozza et al., 2004; Villa et al., 2002


To extract or not

Exo (n=20) vs. Non-ex (n=20)

followed from 12 to 15 y.o.

similar growth was seen for• Oropharyngeal volume• Minimal Axial Area

Valiathan et al., 2010


Where to refer• Pediatric Dental Sleep Apnea (PDSA) network

• Multicentre incidence study of craniofacial morphology in children assessed in sleep clinics

CAPD/ACDP Montreal 2014 09 13 · PDF file2% Huynh et al. 2012 AJODO ... mandibular rotation,...

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