PART III: EP MAGAZINE SLEEP SERIES

CLINICAL SIGNS OF SLEEP-DISORDERED BREATHING IN CHILDREN WITH DISABILITIES

BY DR. AUDREY YOON, DR. LINDA PHI, DR. JOOROK PARK, DR. HEESOO OH, DR. STEVE PERLMAN AND DR. ALLEN WONG

What is sleep-disordered breathing?

Sleep-disordered breathing (SDB) is a term used to describe a broad range of breathing difficulties or disruptions during sleep. It ranges from mouth breathing and snoring to obstructive sleep apnea (OSA) in the advanced stages, and this disruption in sleep can potentially affect the child's growth and development into adulthood.

Is sleep-disordered breathing more prevalent in children with disabilities?

Yes! In the general population, SDB has a prevalence of up to 25% in children, and OSA has a prevalence of 1-4% in children. These numbers increase significantly in children with developmental disabilities, specifically Down syndrome (Trisomy 21). The prevalence of SDB and OSA in children with Down syn drome increases to about 50% and 30-80%, respectively. They are highly susceptible to SDB due to their large tongue, weaker muscle tone (including neck and airway muscles), and smaller upper airway size.

Although SDB and OSA is widely discussed in Down syndrome, it is prevalent in other disabilities as well. Approximately 80% of children with Prader-Willi syndrome have OSA due to weaker muscle tone and obesity. Children with epilepsy have a higher risk of sleep apnea, and this disruption in sleep can, in turn, increase the frequency of the seizure. Research has shown that treating OSA can reduce this frequency. Infants and children with Pierre Robin sequence are at higher risk of SDB due to a smaller lower jaw (mandible), a narrower upper jaw (palate) due to an opening of the palate at birth (cleft palate), and a tongue that is positioned farther back.

What are the signs and symptoms?

Snoring is the most common symptom of SDB in children. In addition to snoring, other signs of SDB, such as mouth breathing, sleep restlessness, sweating in sleep, dental grinding, bedwetting— and daytime symptoms such as learning problems, challenging behaviors, hyperactivity, and attention issues have been shown to be indicators for more severe sleep disturbances and sleep apnea as they grow older. It is important to note that snoring does not necessarily equate to sleep apnea and that some children do not snore loudly or at all.

How is sleep-disordered breathing or sleep apnea diagnosed?

A sleep study, also called polysomnography (PSG), is currently the gold standard to diagnose SDB and sleep apnea. However, a sleep study takes significant time, cost, and effort for the patient, and so it is not widely accessible for everyone.

It is important to find the underlying cause for SDB in order to properly find the best treatment option. The first line of treatment is typically tonsil and adenoid removal. If the tonsils and adenoids are enlarged or enflamed, the otolaryngologist (head and neck sur geon, ENT) may recommend their removal in order to reduce the obstruction in the airway. A CPAP may also be recommended, though compliance will need to be taken into consideration.

Mouth breathing can be addressed with proper diagnosis. Is your child mouth breathing due to a tongue tie? If so, then a tongue tie surgery  then a tongue tie surgery (lingual frenectomy) may be indicated, paired with myofunctional therapy in order to increase the tongue's range of motion. Or are they having difficulty breathing through their nose (e.g., large turbinates, allergies), and therefore have to rely on breathing through their mouth? If this is the case, treating the allergy or decreasing nasal resistance is important. Orthodontists can play an important role in modifying skeletal growth by widening a narrow palate, using an appliance called an expander. This in turn increases the width of the nasal floor and nasal cavity, helps facilitate easier breathing through the nose, and decreases the need for mouth breathing.

Whatever the case may be, interdisciplinary care is recommended in order to properly address the SDB. Treatment for SDB in children is typically not solved with only one treatment modality, but an individualized treatment plan tailored to each child.

As a parent, what can you do?

As indicated above, having a sleep study for your child and working closely with an otolaryngologist is important to properly diagnose SDB and OSA. These clinical signs may put your child at risk: large tonsils, mouth breathing, difficulty in closing lips together, tongue tie, narrow palate, and dental wear. A pediatric dentist or orthodontist can help you identify these factors as well; they can help address those issues in order to reduce your child's risk of SDB and sleep apnea. We know how important sleep is for a developing child, and so we want to arm you with all the resources possible in order to improve and facilitate their overall growth and development. •

SOUND SLEEP : WHAT ARE CLINICAL SIGNS OF SLEEP-DISORDERED BREATHING?

Keeping in mind that the absence of these symptoms doesn't exclude obstructive sleep apnea, here are some symptoms to watch for:

1. MOUTH BREATHING

Large tonsils, adenoids, and turbinates in the nose were traditionally believed to be the only factors that led to mouth breathing and airway obstruction. However, they found that removing the adenoids and tonsils was not always successful in treating the mouth breathing. A more comprehensive approach evaluates not only the size of the tonsils and adenoids, but also uncovering the underlying cause of the mouth breathing. Mouth breathing can increase the inflammation seen at the tonsils and adenoids, which would result in them being bigger. These bigger tonsils and adenoids would further obstruct the airway, resulting in the child to rely even more on mouth breathing, creating this endless cycle that perpetuates the mouth breathing and inflammation. The clinical threshold for this clinical sign is the inability to breathe through the nose with lips closed for more than three minutes.

2. DIFFICULTY CLOSING LIPS TOGETHER

Another factor is difficulty in closing lips together, also known as "mentalis strain" or "lip incompetence." When trying to close their lips, a strain or dimpling is seen in the chin and the lips struggle to come together. This is a result of an underlying skeletal discrepancy in jaw development. Two scenarios can occur in which mentalis strain is seen: 1) the top jaw is located significantly more forward and the lower jaw is significantly more back, resulting in a large "overjet" or horizontal distance between the top front teeth and the bottom front teeth (incisors); 2) long, narrow face, known as "adenoid facies" resulting from the lower jaw developing excessively downward and backwards. Being mouth breathers predisposes children to develop these long faces since they constantly have an open mouth posture. Mouth breathing can contribute to a dry mouth condition and contribute to risk for dental caries and periodontal disease.

3. NARROW PALATE

Proper development and widening of the top jaw (palate) requires normal tongue function during swallowing, breathing, and function. If your child is a mouth breather, has a low tongue posture, or is tongue tied, the top jaw becomes underdeveloped and constricted. A crossbite is often seen in the very back teeth (molars), when the top back teeth are located inside the bottom back teeth during biting. This can occur either on one side or both sides, indicating that the top jaw is narrower compared to the bottom jaw.

4. DENTAL WEAR

The exact cause of dental wear, also known as bruxism, is poorly understood. However, there appears to be an association between dental wear and SDB and other sleep disorders. It is postulated that interruptions, or constant arousals during sleep, may activate the muscles responsible for grinding, as a way to compensate for the restricted airway. The dental wear is considered a significant risk factor for SDB if the yellow, middle layer of the tooth (dentin) can be seen. Acids from gastric esophageal reflux ca lso be a risk factor for dental wear/demineralization and common for those with digestive problems and sleep apnea, even in children. Prevention strategies should be considered to avoid dental caries and teeth sensitivity.

5. TONGUE TIE

Tongue tie, also known as ankyloglossia, is another factor that increases the risk of SDB. A tongue tie restricts the tongue mobility, thereby affecting the proper development of the craniofacial structures. Additionally, this restricted mobility can result in a tongue thrust, poor swallowing pattern, and/or low tongue posture. In order to determine if your child has a tongue tie, have them open their mouth and lift their tongue up as far as possible to touch the top front teeth. After, have them move it side to side. If the tongue range of motion in any of those directions is limited (less than 50%), then there is a strong possibility they have a tongue tie. Lastly, have them stick out their tongue past their bottom front teeth. If they have difficulty sticking the tongue far out, or if the tongue looks heart-shaped when extending out, then they may have a tongue tie.

6. LARGE TONSILS

Also known as tonsillar hypertrophy, large tonsils are one of the first structures that medical providers assess due to their obstruction of the upper airway. Large tonsils can be seen by having your child open his or her mouth widely. A tongue depressor can also be used to better visualize the tonsils in the back of the throat. They are considered to be large if they occupy more than 50% of the space upon opening.

ABOUT THE AUTHORS:

Dr. Audrey Yoon is a dual-trained orthodontist and pediatric dentist. She is also a diplomat of American Board of Dental Sleep Medicine and diplomat of American Board of Orthodontics. She is an adjunct assistant professor in Orthodontics at University of Pacific, an adjunct assistant professor at Stanford University Sleep Medicine Center and also a co-director of Pediatric Dental Sleep Mini-residency program at Tufts University. Currently, her active areas of research include craniofacial growth modification, surgery-first approach of maxillomandibular advancement surgery technique, and the genomic study to identify genetic anatomical factors relating to OSA. Dr. Linda Phi is currently a practicing orthodontist in Southern California. She is a board-certified orthodontist by the American Board of Orthodontics. She is an adjunct professor in the Orthodontics Department at the University of the Pacific (UOP), and is also an adjunct professor in the Orthodontics Department at the UCLA School of Dentistry. She received her DDS and MS in Oral Biology at UCLA, and received her Orthodontics Certificate and MSD at UOP.

at UOP. Dr. Joorok Park is an Assistant Professor and the Clinic Director of the Orthodontics department at University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco, CA. He is a diplomat of American Board of Orthodontics. He received his MSD and Certificate of Orthodontics at University of the Pacific, Arthur A. Dugoni School of Dentistry, and earned his DMD at University of Pennsylvania, School of Dental Medicine. He has done numerous clinical research work at the Craniofacial Research Instrumentation Laboratory.

Dr. Heesoo Oh currently holds Professor and Chair of the Department of Orthodontics at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco, CA. She received her DDS, MS in Pedodontics, and her Ph.D. from Chonnam National University in Kwangju, Korea. She later earned her MSD in Orthodontics at the University of the Pacific. She has received multiple awards and grants from the AAOF, AAO, and NIH. Steve Perlman, DDS, MScD, DHL (Hon.) is the Global Clinical Director and founder of Special Olympics Special Smiles. Dr. Perlman has extensive experience through his private practice and his role as clinical professor of pediatric dentistry at the Boston University School of Dental Medicine. He has additional academic appointments to NYU, University Pennsylvania School of Dental Medicine, ATSU Arizona School of Dentistry and Oral Health, School of Dental Sciences University of Technology in Jamaica. Founder and past president of American Academy of Developmental Medicine and Dentistry (AADMD).

Allen Wong, DDS, EdD, DABSCD is a professor and the director of the Dugoni School of Dentistry AEGD and Hospital Dentistry program in the San Francisco area, and is the Global Clinical Advisor to the Special Olympics Special Smiles. He is current president of the American Academy of Developmental Medicine and Dentistry (AADMD) and a Fellow of the Santa Fe Group

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