Pediatric Airway SOS
Our role in interdisciplinary management
Courtney Bray, RDH, OMT
Sleep disordered breathing (SDB) is a silent crisis in American children. A study in the Journal of the American Orthodontic Society shows that 90% of children exhibit at least one symptom of SDB, and 60% of children exhibit 4 or more symptoms.1 SDB can be a precursor of obstructive sleep apnea (OSA), a disorder characterized by obstructive apneas and hypopneas due to repetitive collapse of the upper airway during sleep.2 According to the American Sleep Apnea Association, 1% to 4% of children suffer from OSA, therefore early intervention is key-especially when 92.6% of outward symptoms of SDB do not self-correct and 30% will worsen with age.1,3 As dental professionals, hygienists are in the position to investigate the root causes of SDB, so they can be addressed early to inhibit the progression of this disorder.
During my 20-year career as a dental hygienist, I used to advise parents their child would outgrow their bruxism-until I completed Orofacial Myofunctional Therapy training. Afterwards, I started to look at the airway of my dental patients-and my own children-differently. I began to observe their day and nighttime breathing. I noticed different signs and symptoms among my patients, and I realized how many behavioral and developmental issues accompany SDB. As hygienists, it is important for us to have a clear understanding of our role in interdisciplinary management and to expand our knowledge of the airway. The hygienist plays a critical role in early intervention through screening, observations, and solutions.
Screening
Screening with a questionnaire can be done before the patient comes into the hygienist's operatory. The Sleep Disordered Breathing Questionnaire (SDBQ) can be incorporated into new patient paperwork or existing patient updates. This questionnaire should be comprehensive, including daytime and nighttime signs of airway disorders, along with development and behavioral concerns. According to research, "There's solid evidence to show that the ‘soft' modern diet, in conjunction with other factors associated with Western lifestyles, can promote abnormal development of the skull and face, and cause malocclusion, impacted wisdom teeth, and narrow dental arches."4 In addition, children with SDB demonstrate "deficits in neurocognitive performance, behavioral impairments, and school performance."5 Parents often do not want something to be wrong with their children, so part of the process is to educate parents on how this condition is common, but not healthy.
If the practice has cephalometric or CBCT imaging, this can be another tool in the screening process. Keep in mind that these are often acquired in a lateral position, but it is when the patient is in a supine position that the airway may become compromised.
Observations
Observations can be done when performing the oral health examination. Checking for a tongue tie is the first step. Nasal breathing should also be immediately evaluated and addressed. If you find the patient is having trouble breathing nasally, then referral to an ENT would be warranted. Some of the main clinical signs of an airway issue are:
• Tongue tie
• Oral habits
• Venous pooling under eyes
• Enlarged tonsils
• Enlarged/red uvula
• High vaulted palate
• Bruxism
• Chapped lips
• Tongue thrusting
• Gagging
• Malocclusions
• Rolled lower lip
• Speech issues
If you see clinical signs of an airway obstruction, refer to the SDBQ and notify the parent of your findings. If the parents did not mark any symptoms on the questionnaire, politely request that they observe their child for a few nonconsecutive nights over the next week. Ideally, they will take the SDBQ home to include any previous symptoms that they now realize exist. Then you can educate them on why it's important to implement early solutions.
Solutions
It is important that the dental team collaborate with integrative health professionals to offer our patients the best possible care and solutions while investigating the root causes of their SDB. Orthodontic/orthopedic oral appliances are an option to address oral habits, establish a proper oral rest posture, and promote the natural forward and downward growth of the jaws. Myofunctional, craniosacral, and chiropractic therapy are other methodologies to consider. Children should be continually monitored to make sure they reach the goal of healthy restorative sleep and proper daytime breathing.
Evaluating airway disorders is like assembling a puzzle: the right pieces need to be found for each individual patient. A comprehensive questionnaire, observations, and solutions (including a team for collaboration) allows dental hygienists the opportunity to make a huge impact on the children in their community. With more than 25 million adults suffering from sleep apnea, it's critical that we screen children now to improve their future health.2 Together we can make a difference.
About the Author
Courtney Bray, RDH, OMT
Orofacial Myofunctional Therapist
Speaker, Writer, and Educator
Inside sales representative, HealthyStart
Frederick, Maryland
References
1. Stevens B, Bergerson EO. The incidence of sleep disordered breathing symptoms in children from 2 to 19 years of age. Journal of the American Orthodontic Society. 2016;16(1):24-28.
2. Baldassari C. March 1-7 is National Sleep Awareness Week—information for your patients: sleep apnea. American Academy of Otolaryngology. 2020;32(3). https://bulletin.entnet.org/article/march-1-7-2020-is-national-sleep-awareness-week-information-for-your-patients-sleep-apnea/. Accessed May 22, 2020.
3. American Sleep Apnea Association. https://www.sleepapnea.org/treat/childrens-sleep-apnea/. Accessed May 22, 2020.
4. Garnas E. How the Western diet has changed the human face. Darwinian Medicine. February 16, 2016. https://darwinian-medicine.com/how-the-western-diet-has-changed-the-human-face/. Accessed May 22, 2020.
5. Trosman I, Trosman SJ. Cognitive and behavioral consequences of sleep disordered breathing in children. Med Sci (Basel). 2017;5(4):30.
