Prevention-The Key to Treating OSA/SDB-
Part II
Many morphometric features
that put adults at risk for OSA/SDB are present during childhood
and it is important for sleep specialists to recognize these
features and treat them early.
By Brian G. Palmer, DDS
Most lactation (breast-feeding) specialists know very little
about obstructive sleep apnea (OSA)/sleep-disordered breathing
(SDB), and most sleep specialists know very little about
the importance of breast-feeding. It is in the hopes that
the second part of this article will help educate both sides
to the fact that there is a strong relationship between
the specialties, and that both specialties will start working
together to help study and prevent the very serious medical
condition called OSA/SDB.
There are no ideal treatments for OSA/SDB—all have
potential side effects. A tracheostomy, although usually
100% successful, is not a choice most people would prefer.
Patients who use continuous positive airway pressure (CPAP)
often have problems with compliance. Surgeries do not always
solve the challenges of OSA/SDB, and may even make the condition
worse. Oral appliances can move teeth and cause malocclusions
or create temporomandibular jaw (TMJ) problems.
Christian Guilleminault, MD, cofounder of the Stanford University
Sleep Disorders Center, Stanford, Calif, stated at the 2002
American Dental Sleep Medicine Conference in Seattle that
prevention is the best form of treatment for OSA/SDB. This
author also believes prevention is the key. In order to
prevent OSA/SDB, however, one needs to understand some of
the factors that affect it. It is important to note that
OSA/SDB is not just limited to obese people and there is
more to OSA/SDB than the results from a sleep study.
Guilleminault has coauthored articles1-2 that
describe the risk factors of OSA. These factors include
a high palate, narrow dental arches, overjet, high body
mass index (BMI), and a large neck. If an individual does
not have a high BMI or large neck size, then the predictive
factors for OSA are a high palate, narrow dental arches,
and overjet.
In another article by Guilleminault,3 he states that inherited
craniofacial features can be a strong indicator of risk
for developing OSA. Genes are factors in facial form; however,
many facial forms are influenced by habits.
Kushida et al4 stated that abnormal tongue activity is also
a predisposing factor for OSA. Some abnormal tongue activity
is genetically linked, but is mainly the result of bottle-feeding
and excessive noxious habits such as pacifier use, digit
sucking, lip sucking, arm sucking, and blanket sucking.5
Morphometric features
Anything that contributes to the blockage or collapse of
the oral cavity and/or airway space can contribute to OSA/SDB.
Factors that can contribute to blockage or collapse include:
* grossly enlarged tonsils and adenoids
* macroglossia
* elongated soft palates and enlarged uvulas
* polyps, tumors, and other abnormal growths
* facial-skeletal growth abnormalities
* central nervous system dysfunction affecting facial muscles
* ankyloglossia (tongue-tie)6
* large tori
* improper feeding of infants (using artificial bottles
and nipples)
* noxious habits that include pacifier use, arm sucking,
lip sucking, blanket sucking, and excessive digit sucking
* drugs or diet7
Breast-feeding
Breast-feeding is important for the proper development of
the swallowing action of the tongue, shaping of dental arches,
and proper alignment of the teeth.8,9
The tongue contributes to the developmental shaping of the
palate9 during its motion across the palate during a swallow.
Insert a bottle or pacifier between the tongue and the palate
and the tongue cannot reach the palate. The physical contact
of the bottle-nipple/pacifier can actually elevate the height
of the palate. A vacuum created by strong sucking actions
during excessive noxious habits can also increase the height
of the palate.9
Figure
1. Adult swallowing pattern.
From a dental or oral cavity developmental perspective,
the importance of breast-feeding is for a proper swallowing
pattern to be developed. The swallowing pattern developed
during infancy extends into adulthood. A proper adult swallowing
pattern (Figure 1) is initiated with the tip of the tongue
on the maxillary anterior papilla area just behind the maxillary
front teeth. The tongue then continues across the hard palate
in a peristaltic-like motion pushing either a bolus of food
or saliva ahead of the motion. Near the end of the swallow,
the tensor palatini muscles fire and open the eustachian
tubes. The levator palatini muscles and the tensor palatini
muscles elevate and tense the soft palate so that food and
water will not escape through the nose. During a normal
correct swallow, the tongue should not exert any pressure
on any teeth. The tongue should then rest against the anterior
portion of the hard palate until the next swallow.
During bottle feeding, a proper swallowing action may not
develop and a tongue-thrust may develop instead. Not much
muscle coordination is needed during most bottle-feeding,
so perioral, facial, and TMJ musculature may not develop
properly. Some of the time during bottle-feeding, the infant
only needs to squeeze on the nipple to express formula from
the bottle. At other times, the infant may have to suck
excessively to remove formula from the bottle. Since the
hole at the tip of the nipple is not regulated to a standard
size, the size of the hole can be quite variable. A nipple
with a large hole may gush out an excessive amount of formula
that could possibly choke the infant. The infant has to
place the tongue at the back of the throat in a protective
posture so that too much formula does not go down the throat.
If the hole is too small, the infant may have to suck on
the nipple excessively to express the formula. As formula
is removed, a vacuum can be created inside the bottle. More
suction is then needed to remove the formula. The greater
the sucking action needed within the mouth, the greater
the potential for collapse of the oral cavity.
Figure
2. Adult tongue-thrust.
During bottle-feeding, the position and action of the tongue
are different than during breast-feeding. Since most bottle-nipples
are firmer than the breast, the tongue gets drawn inside
the mouth to protect the bottom side of the tongue from
being traumatized by the gum pad.10 A tongue-thrust (Figure
2, page 55) is most likely to develop when this occurs.
The excessive vacuum that may be needed during bottle-feeding
and the development of a tongue-thrust are the main contributing
factors to the malocclusions that put an individual at risk
for OSA/SDB. The above is also true for excessive use of
pacifiers, digit sucking, blanket sucking, and arm sucking.5
Related articles
Paunio et al11 found that dummy and digit sucking
was strongly associated with malocclusion and found that
35% of 3-year-olds had a malocclusion. Melsen et al12
found that digit and dummy sucking resulted in increased
tendency to tongue-thrust, and tongue-thrusts were related
to open bites, cross bites, overjet, and Class II malocclusion.
It was concluded that sucking habits influence the etiology
of malocclusion. Davis and Bell13 demonstrated
that there was a strong association (P=>.0006) between
exclusive bottle-feeding and malocclusion, and that the
relationship did not diminish as the child grew from the
primary to permanent dentition.
A study by Farsi et al14 demonstrated that digit and dummy
sucking was the lowest among children who had a good opportunity
for breast-feeding and that there was a significant relationship
between sucking habits and malocclusion such as Class II
malocclusion, increased overjet, and anterior open bites.
The principal finding in the study by Labbok and Hendershot15
was that the longer the duration of breast-feeding, the
lower the incidence of malocclusion. The study also found
that bottle-feeding leads to a habit of tongue-thrusting,
and there was a significant decrease in tongue-thrusting
with an increased duration of breast-feeding.
A tongue-thrust is probably the biggest contributor to the
development of a malocclusion and to the relapse (failure)
of most orthodontic cases. To observe a tongue-thrust, one
just has to have a person with a malocclusion close the
mouth, then slightly separate the lips, and then have the
individual swallow. If the individual has a malocclusion
with spaces anywhere in the mouth, one will be able to see
the tongue extend into the space(s) during the swallow.
Saliva may also ooze between the teeth. During a correct
swallow, the tongue should be on the roof of the mouth and
the saliva should be forced distally into the throat, not
forward between the teeth.
Adults do not form the morphometric characteristics that
put them at risk for OSA/SDB overnight. They had those characteristics
when they were young, but nobody understood or appreciated
the consequences of those characteristics.
In 1996, the American Academy of Pediatric Dentistry (AAPD)16
stated that 89% of youth, ages 12 to 17, had some occlusal
disharmony, and that 16% of youth had such severe handicapping
malocclusion that treatment was mandatory. In 1997, Victora
et al17 conducted an epidemiological study, which showed
that pacifiers were commonly used by 85% of infants in her
study by 1 month of age. She also found that children weaned
from breast-feeding early use a pacifier more often than
those who were breast-fed longer. The Victora and AAPD findings
should be alarming. Is it just by chance that these percentages
are so similar? This is extremely significant once one realizes
that in prehistoric times, and in nonindustrialized cultures
as recently as the 1930s,7 people had minimal malocclusions.
Shepard et al18 stated that the largest increment of craniofacial
development occurs within the first 4 years of life and
that 90% of craniofacial development is complete by the
age of 12. Since 90% of craniofacial development has occurred
by that age, then it is very likely that the morphometric
features that put adults at risk for OSA/SDB were probably
present at age 12. Addressing and correcting these features
early may significantly reduce the medical problems that
many children have as a result of undiagnosed OSA or upper
airway resistance syndrome. The most important thing in
life is one’s ability to breathe. A person’s
health is directly related to their ability to breathe oxygen.
If a child or an adult cannot breathe well, then their health
will be affected in some way.
Most children are not screened or tested for OSA/SDB and
therefore are not diagnosed with the condition. The reason
for this is that many physicians, especially pediatricians,
are still unaware of the relatively new field of OSA/SDB.
Conditions such as bed wetting,19,20 behavioral problems,21
and attention deficit hyperactivity disorder22 could possibly
be prevented if infant sleep problems were addressed early.
Figure 3. Massive tongue.
Figure 4.
Adult tori.
Oral Characteristics of Sleep Apnea
Anything that decreases the normal volume of the oral or
nasal cavity can contribute to OSA/SDB. Some factors that
can contribute to decreased size include tumors, large tongues,
and tori. Large tongues are due to genetics, while tori
are due to clenching and bruxing (Figures 3 and 4, page
56). Tongue-based obstructions can be checked by pulling
the tongue forward out of the mouth with gauze and then
having the person breathe while the tongue is advanced.
Those with obstructions at the tongue base can many times
immediately note better airflow. Obstructions to nasal airflow
can be checked by visual inspection using a nasal spectrum
or by blocking one side of the nose while having the patient
breathe through the other side. One should also note the
shape and collapsibility of the nose.23
Individuals with long face syndrome (LFS)24 are also at
high risk for having OSA/SDB. Although some individuals
with LFS have a genetic predisposition for it, many have
the disorder because of large tonsils or an obstruction
in the airway that forced them to become mouth breathers
when they were youngsters. The chronic mouth breathing can
then lead to a narrowing or collapse of the face.25
Conclusion
We are seeing just the tip of the iceberg when it comes
to the medical expenses associated with OSA/SDB. Most of
the morphometric features that put an adult at risk for
OSA/SDB are present during early childhood. It is up to
health care providers to recognize these features and treat
them early. Many of our children are suffering disorders
related to airway resistance and poor quality of sleep.
By treating early, we, as a society, can have healthier
children as well as lowered health care costs. Treatments
can be as simple as rapid palatal expansion before the fusion
of the midpalatal suture line, removal of massive tonsils,
or correction of a Class II malocclusion at the proper growth
period. Prevention is the best and cheapest way to treat
OSA/SDB. The best prevention is breast-feeding and keeping
pacifiers out of the mouths of our children. Breast-feeding
is the best form of health care we can give children. It
is free to all children. Not only are there nutritional,
immunological, and psychological benefits of breast-feeding,
there are also the benefits of a better occlusion and a
reduced risk of OSA/SDB. All health care providers need
to understand the benefits of breast-feeding and need to
encourage it as much as possible.
Brian G. Palmer, DDS, is a full-time general dentist in
Kansas City, Mo, who has a special interest in the cause,
prevention, and treatment of obstructive sleep apnea.
References
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