Pamela A Nicoara DDS MSD PLLC

PERIODONTOLOGY IMPLANTOLOGY ORAL MEDICINE

3125 Colby Avenue, Suite H Everett WA 98201

T: 425-374-5380 F: 425-374-5382

www.NICOARAperio.com doctor@NICOARAperio.com

VOLUME 9, NO. 2

AUGUST 2016

A QUARTERLY PERIODONTAL

NEWSLETTER

BY PAMELA NICOARA DDS MSD

Airway and Dentistry

PROBE TIPSDiagnosis

Disorderedbreathingiscausedbyablockageoftheairway.Whentheblockageismild,snoringistheresult.Iftheblockageissevere,aswithseveresleepapnea,apersonmaystopbreathingforminutesatatimebeforetheywakeupenoughtogaspforair.

Theblockageoftheairwaycanoccuratvariouspointsintherespiratorysystem.Mostlikelyareasofblockageare: •Enlargednasalturbinates,deviatedseptum,

and/orweaknasalcartilage•Sinusblockage(allergiesorinfection)•Largetonsils/adenoids•Largetongue,uvulaand/orsoftpalate•Retrudedlowerjaworupperjaw•Excessiveneckfat•Smokingorsecondhandsmoke

Thegoldstandardfordiagnosisofsleepdisorderedbreathingismadebyparticipatinginasleepstudy.Thisusedtobeavailableonlythroughaninconvenientandsometimescostlyovernightstayinthehospital.Today,however,therearehometestingkitsthatamedicaldoctorcanprescribe.Theseareoftenusedasascreeningtoolsuchthatifapatienthasseveresleepapnea,theystillmayberequiredtohaveaformalsleepstudyinthehospital.Diagnosiscanalsobemadethrough

screeningQuestionnaires,orsubjectivelybyabedpartnerwhocanheartheotherpersonsnoring,grindingtheirteeth,orgaspingforair.Itcanalsobemadeontheappearanceoftheteethandface:peoplewhomostlikelycannotbreaththroughtheirnosewillbreaththroughtheirmouths,have‘longfaces’,haveforwardheadposture,orswollengumsandpuffylips(seeimageonfrontpanel).

sleep disordered breathing

Weareinauniquepositionindentistrytohavetheopportunitytorecognizeandhelptreatpatientswithairwaydisturbances.Maybewithoutrealizingit,youseepatientswithairwayobstructiononaregularbasis.Thesepatientsincludethosewhoaremouthbreathers,havenarrowV-shapedmaxillaryarches,anterioropenbite,orposteriorcrossbite.Althoughairwayislikelyobstructedatalltimes,itisprobablymostdetrimentalovernightduringsleep.

SleepdisorderedbreathingisdeRinedassleepdisturbancecausedbyabnormalbreathingpatterns.Thisincludessnoring,upperairwayresistancesyndrome(UARS),andobstructivesleepapnea(OSA).Thesemanifestationsofsleepdisturbancesareoftenconsideredacontinuumthatstartswithsnoringandcaneventuallybecomeobstructivesleepapneaiftherightconditionsdevelop(suchasweightgainorsedativeuse).

Forchildrenwithcompromisednasalpassagesearlyinlifecausingmouthbreathing,theupperjawdevelopmentisalteredandnarrowedbecausethetongueisnotpassivelyrestingagainstthepalatetocreatetheopposingforceforthecheeks.Theteethmovelinguallyandthejawrotatesopen.Lackofsleepinchildrencancausestuntedgrowth,andleadstoADHDcausingdelayedcognitivedevelopment.

Foradults,lackofsleepcanincreasedaytimesleepiness,chronicfatigue,headaches,poorworkperformance,gastricreRlux,sorethroat,toothwear,diabetes,hypertension,depression,heartattack,strokeandprematuredeath.

ThisissueofProbeTipswillexplorethevariouscausesandtreatmentsforairwaycompromiseanditsrelationshiptodentistry.

Copyright2016Dr.PamelaNicoara

TakenfromGoogleImages

Oral Appliance and myofunctional therapy

Formildapnea,orinsituationswhereaCPAPisnottoleratedbythepatient,anoralappliancecanbefabricated.Thesedevicesareprimarilyusedtoadvancethemandibleforwardandpullthetongueandsofttissuesawayfromthethroattoopentheairway.Thesedevicescanbeveryeffectiveforlesssevereformsofobstructionorsimplytoreduceoreliminatesnoringnotassociatedwithsleepapnea.TheyarebeneRicialforthosewhocannottoleratetheCPAP,buttheycanneverbeaseffectiveasCPAPiftheapneaissevereenough.

Occasionalsideeffectsoforalappliancesincludeunintendedtoothmovementiftheappliancedoestocoveralltheteeth.SomepatientsmaynotejointtendernessordifRicultyclosingtheteethinthemorningwithouttheuseofare-positioningdevice.

Anothertreatmentforlesssevereformsofairwayresistanceismyofunctionaltherapy,ortreatmentaimedatstrengtheningthemusclessurroundingtheairwaytomaintainpatencyovernight.Thishasbeenshowntoimprovesleepparameterseveninpatientswithsevereformsofsleepapnea.

ReferencesCleveland Clinic Med Ed Garcha, P et al. 2013. SLEEP Camacho, M, et al. 2015. CoDAS Correa C, et al. 2015. J Cranio Sleep Pract Rouse, J. 2016.

*Complete references available on request.*

Types of Treatment for Sleep Disordered Breathing Surgery

SurgicaltreatmentisthemostdeRinitivemeansofcorrectingairwayobstruction.Thetreatmentvariesdependingonthelocationoftheblockageintheairway,andyourage.

Forchildren,enlargedtonsilsandadenoidsarethemostcommoncauseofnasalobstructionandmouthbreathingleadingtosleepdisorderedbreathing.Eveninfantscanbetreatedsurgicallyiftheobstructionislargeenough.ItisoftenconsideredtheRirstlineofdefenseinpreventingconcomitantorthopedicchangesintheheadandfaceifthebodyadaptstoobstructionduringdevelopment.And,ofcourse,ifanadulthasbeendiagnosedwithenlargedglands,thensurgicalremovalcanoccuratanyage.

Reductionoflargenasalturbinatesordeviatedseptumisalsoarelativelynon-invasivesurgicaltreatmentthatcanbeperformedevenearlyinlifeinthepreventionandtreatmentofobstruction.

Ifcaughtearlyenoughindevelopment,orthodontictreatmentcantakeadvantageofthepotentialformoreextrememovementsinthegrowingindividualtomovetheteethandjawstocorrectpositionstomaximizeandmaintainairwayspaceoncetheobstructionisremoved.

Oncedevelopmentiscompleted,andcraniofacialchangesare‘permanent’,thenorthognathicjawsurgerytoadvancethemaxillaormandibleorexpandthepalatewouldbenecessarytocorrectmalocclusionassociatedwithobstructionandopenairwaysforimprovedbreathing.

Finally,more‘specialized’surgeriescanbeperformedtoreducethesizeoftheuvula,softpalateortongueifallothertreatmentsareineffective.

Copyright2016Dr.PamelaNicoara

Continuous positive airway pressure

(CPAP) CPAPisconsideredtheidealmethodfor

treatingseveresleepapnea,butcanbeusedformoremildformsaswell.CPAPisveryeffectiveforcontrollingsleepapnea,butisnotalwayswelltolerated.AsigniRicantnumberofpatientscan’tsleepwiththemachineontheirface,feelitistooconRining,orjustplainuncomfortable.CPAPmachineshavecomealongwayovertheyears.Theyarenowmoresophisticatedsothatairpressuredeliveredtothenoseand/ormouthisregulatedtobestrongerwhenonyourback,andstrongerwhenyouarebreathingin.Conversely,whenonyourside,orbreathingout,thepressureisreduced.Thereisalsohumiditycontroltopreventnaso-oraldryness.

Withregardtodentalcare,thesepatientsmayhaveincreasedriskforcariesorperiodontitisduetooraldryness.Oralhygieneinstructionsforoptimalhomecareandregulardentalvisitsareparamount.

ItisimportanttorealizethatCPAPisatreatmentthatdoesnotnecessarilyaddressthecauseoftheapnea.Ifthepatientisoverweightorhasnasalobstruction,treatingthoseproblemsRirstmayeliminatetheneedforaCPAPaltogether.However,sometypesofsleepapnea,forexample,centralsleepapneawherethebrainsimplydoesnotgivethesignaltothediaphragmforinhaling,wouldrequireCPAPasthemaincurativetreatmentmodality.

TakenfromGoogleImages

TakenfromGoogleImages

General Considerations

Treatmentforsleepdisorderedbreathingisdeterminedbythelevelofdisorder,andpatienttolerance.Asleepstudywillclassifypatientsintomild,moderateorseveresleepapneaversusUARSbasedonhowmanytimespernightbreathingstops(calledtheapnea/hypopneaindex(AHI))andhowlowbloodoxygendrops.AnAHIofupto5episodesperhourisconsiderednormal. •MildApnea=AHI6-10•ModerateApnea=AHI11-20•SevereApnea=AHI21+

common sense treatments

Weoftenforgetthatourbodiesarecomplicatedmachines,andthatseeminglyunrelatedpartsofourbodieshaveprofoundeffectsonothermembers.

Forchildren,eliminatingsecondhandsmokeortreatingseasonalallergiescanbeveryeffectiveatreducingtheinRlammationinthenasalpassagesthatresultfromsuchinsults.

Oneofthemostobvious‘treatments’foradultsisweightloss.Meninparticulargainbellyfatorneckfatthataddsweightinthechestwhenrecumbentmakingithardertobreathe.Improvingphysicalactivityanddietwillnotonlyreduceweightandreducelaboredbreathing,itwillimproveimmunefunction.Inaddition,avoidingalcohol,sedativesormusclerelaxantsatnight(whichwillfurtherreducethemuscletoneinthethroat)willhelpensureabetterairwayovernight.Sometimes,fornormalweightindividuals,somethingassimpleasaBreatheRightStripcanopenthenasalcartilageandkeepairRlowingthroughthenose.