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 [email protected]
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.
Recommended
