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Defining the role of Dentistry in pediatric sleep medicine

September 23, 2015

As dental teams develop a deeper understanding of their role in the diagnosis and treatment of sleep apnea and sleep disordered breathing in adult populations. It has become clear that there is a large population of sleep patients that are currently minimally served by the dental community. Children with sleep disorders do not present in the same way as adults, and their caregivers often do not have a good understanding of how to identify sleep disorders or if they do, who to ask for help. I have always considered the dental team the front line of community health. The 6 month recall is an excellent way to monitor the medical and dental health of a patient. The article below by Sonia Smith CPNP/CNS sets out the roles and responsibilities or the dental and orthodontic team.- ed

Children often have two consistent sources of medical care in their lives:  their primary care providers and their oral health professionals.  Both sets of experts are in prime positions to identify children with the potential for sleep disordered breathing.  Unfortunately, most health professionals receive little formal training about the assessment, diagnosis, and treatment of pediatric sleep disorders.  In addition, parents and caregivers have been shown to inaccurately identify signs of sleep disturbance in their children.  This makes them less likely to report problems with their child’s sleep to healthcare providers.  Therefore, it is important that all professionals who assess the health of children, including pediatric dentists and orthodontists, become part of a collaborative team to help identify, treat, and refer children with suspected sleep disorders.

Approximately 20-30% of all children have problems related to sleep.  The percentage of children who snore accounts for approximately 3-12%.  Sleep disordered breathing occurs in about 2% of children and 2.5-6% of adolescents.  The neurocognitive and physical effects of poor sleep in pediatrics is well-documented in the literature.  Children and adolescents may suffer from hyperactivity, inattention, aggression, depression, diminished cognition and decreased executive functioning skills as a result of inadequate sleep.  Children and adolescents with sleep disorders are more prone to develop obesity, have delayed growth and development, to suffer an increased rate of injury, and to manifest changes in immune system functioning.  As in the adult population, non-restorative sleep and sleep disordered breathing in children has been shown to exacerbate or contribute to chronic illnesses and to contribute to permanent changes in cardiovascular functioning.

The primary roles of the pediatric dentist and orthodontist are to identify physical exam findings that may impact sleep behavior and to make appropriate referrals.  Common abnormal findings on the oral examination of children include tonsillar hypertrophy, dental malformations secondary to thumb sucking or pacifier use, palate deformations, evidence of bruxism, malocclusion, and other craniofacial anomalies.  Positive physical findings, along with a brief sleep screening questionnaire such as the BEARS (B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) Sleep Screening Tool can provide excellent evidence to warrant a referral to a pediatric sleep specialist for further investigation.

Polysomnography (PSG) can guide the clinical practice of pediatric oral care professionals.  The treatment of children with sleep disordered breathing identified on PSG is varied.  The most common therapy involves tonsillectomy and adenoidectomy.  However, a significant number of children have residual sleep disordered breathing even following surgical intervention.  Malformations in craniofacial structures may remain and continue to pose a significant risk for obstructive breathing.  Orthodontic intervention and myofascial reeducation may be options for treatment of residual problems.  Oral appliance therapy, while currently not often utilized in pediatrics, may become a more significant treatment option in the future.

Pediatric dentists and orthodontics can be valuable in detecting subtle signs of and providing treatment recommendations for midface hypoplasia that can occur in patients with long term use of CPAP or BiPAP.  Coordinating care with the pediatric sleep specialist can help to prevent acquired facial deformities in pediatric patients and to prevent further orofacial complications that contribute to sleep disordered breathing.

Pediatric oral care professionals have a very important role in the sleep health of pediatric patients.  Collaboration with the child’s primary care providers, sleep specialists, and other subspecialists is the optimal way to identify potential sleep issues in a timely manner.  In this way, children can receive early diagnosis and treatment in the hope that they will be spared the negative physical and neurocognitive effects of poor sleep.

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