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Identifying Sleep Disordered Breathing in Kids

Identifying sleep disorders in pediatric patients requires more observation than questions, as with adults.

The #1 factor affecting sleep in kids is enlarged tonsils and adenoids. Decreased oxygenation because of the airway restriction upregulates the sympathetic nervous system (fights or flight part of our nervous system) and children react as if they are fidgety, distracted, ADD/ADHD-like behaviors, such as emotional outbreaks or over-reaction to stimuli. They may have trouble focusing or concentrating. These behaviors can likely be identified in younger patients (up to middle school).

Large Tonsils in 17 Y/O and Long Swollen Uvula

If they have large tonsils, a tongue that seem too big, narrow arches; all are signs of airway restriction. Just because you can’t see the tonsils, doesn’t rule out enlarged adenoids (tonsil tissue at the back of the nasal airway). These children will typically have dark rings under their eyes and mouth breathe.

 

 

 

 

Worn Teeth

Children or teens that present with worn or chipped teeth from grinding have a high likelihood of sleep disordered breathing. Bruxism is a known marker for a sleep disorder in children. As in adults (but more pronounced in kids), clenching/bruxing is thought to be a reaction to a collapsing airway as inspiration begins. Stress is not a valid explanation in the orthopedic TMJD and sleep literature for parafunction, although there are rare exceptions.

 

This patient was referred to me for TMJ popping and pain and headaches; after imaging her airway she was referred to have her tonsils and adenoids out, which stopped the clenching (that had damaged her TMJ’s), as a result slept better, was no longer fatigued, no longer had to nap after school, and her behavior “calmed down”. Her TMJ’s rehabilitated with orthotics as she slept better.

Children with SDB (Sleep Disordered Breathing) can have painful jaw muscles and headaches, but won’t typically report it. Push on the masseter & temporal muscles and press over the jaw joints. Pain is an indication of parafunction, as is clicking/popping.

Narrow maxillary arches is another sign identifying mouth breathing. Children who mouth breathe have maxillary arches that have a high palatal vault, are more “V” shaped than horseshoe-shaped and have less spacing between primary teeth. Bicuspid depression indicates a chronic mouth breathing condition.

Tongue “Too Large” and Overlays Posterior Teeth and Narrow Arch

Reports of children being difficult to put to bed at night and who resist getting up in the morning are another suggestion of improper sleep.

Bed wetting can be a sign that deeper sleep stages aren’t being achieved. Deep sleep, the bladder is inhibited from filling. Patients who don’t spend enough time in restorative sleep stages have to go to the bathroom a couple times per night. Children may wet the bed unknowingly.

We must keep examining patient’s mouths, throats, and teeth from a sleep/parafunction connection. TMJ clicking and pain is also a sign that they are clenching or grinding at night and has a strong correlation to sleep disordered breathing.  TMJ problems especially popping and clicking doesn’t “go away” and is sometimes secondary to the sleep disordered breathing problems.

I am available to consult on any of these issues, and help make referrals for tonsil/adenoid removal with clinical and 3D airway measurement of the tonsils and adenoids.

Dr. Mark Barnes

 

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Waking the Dead (and grumpy): Teenagers and Sleep

Why is it that getting our teenagers up and going is sometimes such a battle?

We nag them to get up, they want to sleep longer

We’re in a hurry- they can’t seem to get out of bed

They stay up too late…

Actually, it’s not totally their fault.  As kids enter teenage years their circadian rhythm, as well as the rest of their physiology, begins to change. All parents know that for sure! Teens are known for staying up late and sleeping in. During teenage years, melatonin’s release (the sleep hormone) is delayed. Teenagers start getting sleepy (melatonin release) around 11pm and need more time to fall asleep.  8-10 hours of sleep is ideal for teens according to the American Academy of Sleep Medicine. They need to sleep until around 7:30 AM.

There is a growing pressure on school systems to change school start times based on research in the sleep literature. It’s being met with resistance because of our work schedules, after school programs/sports and parent’s time schedules. It’s a clash between physiology and a society that has, for decades been on a schedule that seems to have trended earlier over the decades.

According to an article in this month’s American Academy of Sleep Medicine journal:

Short sleep in adolescents is associated with poor school performance, obesity, metabolic dysfunction and cardiovascular morbidity, increased depressive symptoms, suicidal ideation, risk-taking behaviors, athletic injuries, and increased motor vehicle accident risk.917 Increased motor vehicle accident risk is particularly concerning because young, novice drivers have a higher crash risk when sleep deprived, and motor vehicle crashes account for 35% of all deaths and 73% of deaths from unintentional injury in teenagers.1820

Importantly, a delay in school start time has beneficial impacts on teenage students. Studies show that implementation of later school start times for adolescents is associated with longer total sleep time, reduced daytime sleepiness, increased engagement in classroom activities, and reduced first-hour tardiness and absences.7,2123 Delayed school start times also are associated with reduced depressive symptoms and irritability.21,22 Reaction time improves, and crash rates decline by 16.5%, following a school start time delay of 60 minutes.12,13 Extension of sleep time also facilitates behavioral weight loss interventions in adolescents.24.

There isn’t an easy solution to this clash between physiology and society’s needs. But recognizing it can take some of the stress off families. Let the kids schedule relax on the weekends for sleep, talk to them about “sleepy driving” and remaining alert. Perhaps a nap after school would help some of them. If they seem overly tired, they should be screened by a qualified Dentist in sleep/breathing disorders for airway obstructions and altered craniofacial growth that may be a contributing factor.

Citation: Watson NF, Martin JL, Wise MS, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Olson EJ, Ramar K, Rosen IM, Rowley JA, Weaver TE, Chervin RD. Delaying middle school and high school start times promotes student health and performance: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13(4):623–625.

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Why is High Blood Pressure a symptom and side effect of Obstructive Sleep Apnea?

Every time you have an apnea (a total block of air for 10 seconds) or hypopnea (partial breathing block) the “fight or flight” reflex is triggered.

With each event, the heart rate and blood pressure increase.  It’s the same feeling you get when you’re scared suddenly; a little sweating, hard to catch your breath, and your heart pounds for a few seconds.

  1. Apneic’ s have this sympathetic response many times per hour, all night long. The body begins to be in a constant state of alert.
  1. With Sleep apnea, the body is chronically low on oxygen. Oxygen is needed to produce nitric oxide in our sinus’ and blood. Nitric oxide is a potent vasodilator- it relaxes the blood vessels and decreases the work of our heart. In sleep apnea the blood vessels chronically tighten and don’t get to relax and repair. The higher blood pressure causes damage to the inside of the artery. This contributes to plaque and more narrowing. As the arteries get narrower it places a higher burden on the heart which leads to heart attacks, strokes, and chronic high pressure.
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A Good Night’s Sleep

Walking through the airport I saw a cover of Consumer Reports regarding how to sleep better.

It reviewed all types of mattresses, pillows, sleep positions, etc. suggesting that this is the primary cause of poor sleep. Not most likely.

While discomfort in your neck, back, or hips can disturb your sleep, the PRIMARY cause of sleep issues in America today is BREATHING. You’re not breathing well. Sleep Apnea, Upper Airway Resistance, Reactive Airway conditions are the most likely culprits robbing you of restful, restorative sleep.

If you have neck, back, shoulder or spinal disease or pain, the pressure and position you sleep in can cause progressive pressure on discs and nerves as you sleep. As you enter deeper stages of sleep your joints may become “irritated” enough to cause a signal to the brain to move or change positions to lessen the pressure. If it happens often enough you will feel that you’re not sleeping well. These are the conditions that pillows and mattresses can improve.

Most sleep disturbances in adults result from Obstructive Sleep Apnea, Snoring, or other conditions involving airway collapse during sleep. If you snore, there’s a near 70% chance that you have Sleep Apnea or that your oxygen is dropping to levels that increase risk of stroke or heart attacks. That is the first consideration to rule out.

Narrowing of the throat (such as with snoring, gasping, jerking) is a reaction to significant drops in the oxygen in your blood and brain. The brain reacts by sending a “flight or fight-like” surge of adrenaline to jerk or twitch us awake and take a breath (but not awake enough to remember) This can happen many time per hour and rob our body of sleep it needs to be mentally sharp.

Another stage of sleep causes all body muscles to be “paralyzed” and completely relaxed. This is believed to be so that our joints, vertebral discs, and cartilage discs, ligaments can have time to repair and heal from the day’s jarring. The oxygen drops associated with Sleep Apnea episodes (snorts, snoring, gasps) are micro-arousals (mentioned above) that re-engage the muscles and interrupt the joint repair periods of sleep. This can lead to joint discomfort, muscle aches and pains, etc. in the morning. Especially if we already have some “wear and tear” on our joints from sports or activities.

If you suffer from poor sleep, achy tired joints in the neck, back or TMJ in the morning, make sure to have your Physician or a Dental Sleep Specialist evaluate you for potential Sleep breathing problems, in addition to finding comfort with pillows and mattresses.

Our website has a convenient, private self-assessment that you can take and have instant feedback as to risk factors for  a Sleep breathing disorder. TMJ problems are also associated almost 70% of the time to a sleep disorder. Clenching and bruxing are also activities triggered by breathing interruptions that eventually damage the joints and discs, in addition to our teeth.

I work with local Sleep Specialists and Physicians to help determine whether patients with TMJ pain, neck pain, or other symptoms should be screened for a sleep disorder.

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Sleep Disorder Categories and AHI

There are 7 categories sleep disorders as outlined by the American Academy of Sleep Medicine. One of those categories involves all the Sleep Breathing Disorders that Dentists treat under the prescription of a Physician.

Sleep Apnea and UARS (Upper Airway Resistance Syndrome – considered a variant or pre-cursor to sleep apnea) are what we will most often see oral evidence of. Benign Snoring is also under the Sleep Breathing disorders heading. Dentists cannot treat any sleep disorder, including snoring without a physician diagnosing it and writing a prescription for a Dental Sleep Appliance.

Sleep Apnea is scored by a number called the AHI, Apnea-Hypopnea Index. What is that?

Apnea is defined as not breathing for 10 seconds or more with a measured drop in the blood oxygen (the airway is completely blocked). Hypopnea is when the airflow of breathing drops by 50% (because the airway is partially blocked) and blood oxygen drops a certain amount. That’s what defines the AHI.

It’s generally considered normal to have up to 5 AHI’s per hour if you don’t have any other symptoms such as tiredness, heart or blood pressure problems, etc. in adults. If an adult is tired or feels unrested, then the sleep disorder is treated even if the AHI is normal. In children, ANY apnea or hypopnea is considered critical to treat, even grade 1. Their developing brains and bodies need full oxygenation with every breath.

 

The AHI is graded as;
0-5/ events/hour = normal
5-15/hour = mild sleep apnea
15-30/hour= moderate sleep apnea
30+/hour =severe sleep apnea.

 

Urgency develops when we can’t breathe; our brain recognizes that something is wrong…a “fight or flight response” increases the heart rate, blood pressure rises, and anxiety will begin to creep in. That sense will increase as the apnea event lasts longer. Many apneic’s have events lasting 30 seconds or longer. Hypopnea’s cause the same physiologic response, it’s just not as dramatic.

Apnea scoring is tightly regulated for the scoring physicians and technicians, somewhat like periodontal disease. Probing 4mm without bleeding may not qualify for treatment. Same as OSA; An AHI of 5 without sleepiness may not be allowed to get treated. If the patient only stops breathing for 9 seconds, it isn’t apnea. If the oxygen doesn’t drop by 3% in a certain amount of time, it isn’t a hypopnea (partial apnea). Patients may have many non-qualifying breathing events that don’t get scored as sleep apnea. Yet they feel unrested, clench or grind their teeth, have sleep anxiety, etc. Those are the conditions that can be discussed with the sleep physician and have them prescribe a sleep appliance.

We sometimes see a mild sleep apnea worsen when patients start using an oral appliance. Why? They are sleeping better and go in the deeper stages of sleep where more apnea occurs. We screen for those clinical signs at regular follow up visits and have scheduled overnight pulse oximetry testing in our process. We can re-evaluate their mandibular position using pharyngometry and 3D cone beam imaging to assess how they are doing and whether a different jaw position is indicated. Throughout the process, we communicate with the patient’s physician to keep them informed about the process.

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Smoking and Pain: The Untold Relationship

As a Diplomat in the American Academy of Integrative Pain Management, I receive their Pain Practitioner Journal. An article in the December 2016 publication discussed the growing relationship between back pain (orthopedic/joint problems) and smoking. Smoking is referenced to be the root cause of many musculoskeletal disorders because of its relationship to bone damage, the chemicals impair healing in bones and discs, and the chemicals in cigarette smoke sensitize the brain and nerves to pain. Unfortunately this “sensitivity to pain” from smoking takes a long time to go away after quitting smoking and, can be a permanent change in the nerves and brain towards muscle and joint pain.

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Academy of Dentistry International, Fellowship

ACADEMY OF DENTISTRY INTERNATIONAL®

International Honor Society for Dentists promoting social responsibility of the dental profession.

The Academy of Dentistry International is devoted to the advancement of dentistry throughout the world and to the elevation of dental standards by continuing education. Along with the sponsorship of dental education, research and patient care projects, this Academy directly aids in the improvement of the dental and oral health and well-being of people worldwide.

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Nighttime Grinding and Clenching Your Teeth

Do you know if you grind or clench your teeth while you sleep?

Grinding and Clinching Teeth at nightHere are some ways to tell.

I’m just stressed, I’m just an uptight person, I don’t sleep well, etc. Common “explanations” by those who use dental nightguards (and their dentists) for their clenching and grinding. It’s being shown that there IS probably a diagnosis rather than “naming” the symptoms “clenching and grinding” of this sleep disorder.

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What To Look For In A TMJ Doctor

Technology is a Double Edged Sword

Technology is becoming more sophisticated and relied upon everywhere. Some think it is being relied on too much in medicine to the detriment of patient’s care. Other articles propose that a more “robotic” medical world might allow better decisions in health care because it removes human error.

I would opt for more clinical skills vs more robotics in my care. When one person touches another, there is a connection, a sense of trust that a robot or machine cannot instill.

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