May 2020 Volume LV Number 3

 
 
 
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A Clinical Perspective of Obstructive Sleep Apnea in Pediatric Dentistry

March 2020 Volume LV Number 2

Elizabeth Berry, D.D.S., M.P.H., M.S.D.; Andrew Zale, D.M.D., M.S.D.; Jonelle Grant Anamelechi, D.D.S., M.S.P.H.
 
Obstructive sleep apnea (OSA) is a common condition in childhood and can result in significant health complications if left untreated. The American Academy of Pediatrics defines Obstructive Sleep Apnea Syndrome as a "disorder of breathing during sleep characterized by pro- longed partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns."1,2 The prevalence rates range between 1.2 – 5.7 percent.3,4 Early diagnosis of OSA has the potential to decrease morbidity and increase the quality of life, but diagnosis is frequently de- layed. Symptoms and signs of OSA include a history of frequent snoring (≥3 nights/wk), labored breathing during sleep, gasps/ snorting noises/ observed episodes of apnea, sleep enuresis, headaches on awakening, daytime sleepiness, ADHD, and learning problems.1,5 As pediatric den- tists, we are in a unique position to help identify patients at greatest risk. There is no standardized screening tool for pediatric dentistry, but the AAPD policy has valuable questions to ask patients.5 Inclusion of sleep questions on the health history form may assist with identification of patients at risk. The guidelines advise if a patient is suspected of being at risk for OSA, to send the patient to the appropriate medical doctor.5

Here are a few clinical pearls from our colleagues:
  • "Our first question in our practice is to ask if the child snores loudly when sleeping or has trouble breathing while sleeping. If  the answer is yes, then we will continue to ask more questions following the AAPD policy. This helps us identify patients, but also keeps it easier to implement in our practice so we are not asking all patients a list of questions."
  • "To highlight the AAPD policy, the restless sleep inquiry has been an invaluable tool in my practice when screening patients for OSA prior to treatment with Sedation and Anesthesia, with or without snoring. When airway assessment is difficult, I find movement dur- ing sleep is a very good adjunct to Brodsky score as a predictor for potential airway comprise."
  • "Realize that adenoid tissue can cause significant airway compro- mise. While Brodsky examination is important, it is equally impor- tant to realize the potential influence of the unseen adenoid tissue on the airway if a patient is reporting other symptoms of OSA."
  • "If encountering a difficult airway during a dental rehabilita- tion case under anesthesia due to hypertrophy of the tonsillar or adenoid tissue (and other comorbidities associated with OSA are present), it is prudent to document and notify the guardian. This is also your opportunity to strongly advocate for appropriate medical evaluation and intervention."
  • "If  questions are asked about sleep, be prepared to answer: Why does sleep matter to you as a pediatric dentist? Obstructive sleep can lead to other orofacial changes during growth and develop- ment starting at an early age. If we get to the bottom of it now, we may make a world of  difference in overall growth and development (including the head and neck) since growth happens mostly during sleep."
  • "The golden standard of diagnostics in medicine for OSA is a formal sleep study. The final diagnosis takes a lot of different factors into account such as quality of sleep, sleep efficiency, sleep stages, arousals and awakenings, and other respiratory parameters.  If preparing a parent to have a conversation with their medical pro- vider, encourage the family to keep a sleep diary possibly including a video of their child noting sleep times, how long they took to fall asleep, if they snore while they are asleep, if they wake up multiple times, how long they slept, and if they seem rested when they wake up. Remember this may vary with age."
  • "There are multiple approaches that can be taken as a surgical intervention to moderate to severe OSA and it may include remov- ing tonsils and adenoids or just one or the other. There are pros and cons to be weighed for both."
  • "Have a team approach to this care. The work that we do to influ- ence growth and development such as the use of habit appliances, expanders, and bilateral space maintainers can have an effect on airway. Our feedback and work with the team is important also in successful outcomes of care."
REFERENCES
  1. American Academy of Pediatrics. Clinical practice guidelines on the diagnosis and management of childhood obstructive sleep apnea syn- drome. Pediatrics 2012; 130 (3): 576-684.
  2. American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in children. Am J Respir Crit Care Med. 1996; 153(2): 866-878.
  3. Bixler EO, Vgontas AN, Lin HM, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009; 32(6): 731-736.
  4. Li AM, So HK, Au CT, et al. Epidemiology of obstructive sleep apnea syndrome in Chinese children: a two-phase community study. Thorax. 2010;65(11); 991-997.
  5. American Academy of Pediatric Dentistry. Policy on Obstructive Sleep Apnea. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2019:220-4.
 

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