Obstructive sleep apnea syndrome in the pediatric age: the role of the dentist

Sleep disordered breathing in children designates a wide spectrum of respiratory disorders characterized by partial or complete obstruction of the upper airways. It ranges from primary snoring, its mildest clinical manifestation, to obstructive sleep apnea syndrome (OSAS): complete obstruction of the upper airways with cessation of airflow. The aim of this paper is to highlight the roles of the pediatric dentist and the orthodontist in the therapeutic approach to pediatric OSAS as a "sentinel" who can detect early signs of the disease for immediate referral to the otolaryngologist and as an active participant in therapy

The phenotype and genotype of adult obstructive sleep apnoea/hypopnoea syndrome

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldObstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a common condition affecting approximately 2-4% of the middle-aged population. A hereditary component to the condition has long been recognised but its genetic basis has been difficult to elucidate. Progress in determining the genotype of OSAHS is hampered by the lack of a consistent definition of phenotype and the large environmental influences on its expression. "Intermediate phenotypes", such as craniofacial structure, obesity and upper airway control, have been utilised. Multiple gene polymorphisms have been explored in association with the latter, as well as with the sequelae of OSAHS, such as hypertension and increased insulin resistance. To date, two genome-wide scans have identified potential regions that may be of interest in further defining the intermediate phenotypes. The present paper focuses on human studies with an update of the most recent work in the area, including a short discussion on methods of genetic studies

Obstructive Sleep Apnoea: Therapeutic Options and Challenges

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).Obstructive sleep apnoea (OSA) is a common sleep disorder that is associated with significant negative health outcomes including cardiovascular disease, daytime sleepiness, neurocognitive deficits, and increased motor vehicle and workplace accidents. There is wide variation in OSA symptoms and other downstream effects between patients highlighting the need to individualise therapy. Continuous positive airway pressure delivered by a face mask is the gold standard treatment, but adherence to this therapy is poor and improvements in outcomes are often incomplete. A range of alternative treatments are available and may suit different patients. These include behavioural treatments such as weight loss, mandibular advancement using an oral device, sleep posture modification, upper airway surgery, and upper airway muscle stimulation. Towards individualised OSA therapy, novel phenotyping approaches are being developed to identify the specific pathophysiological causes of OSA applying to individual patients. Furthermore, research is underway to help identify patients with OSA at higher risk of daytime sleepiness and adverse cardiovascular and neurocognitive consequences and predict how individuals might respond to treatment. In this article, we review the prevalence, risk factors, and main consequences of OSA; the main treatment modalities available at present; and some new methods for phenotyping patients with OSA that hold promise for a more personalised and effective approach to screening, diagnosis, and treatment

Obstructive Sleep Apnea With or Without Excessive Daytime Sleepiness: Clinical and Experimental Data-Driven Phenotyping

Introduction: Obstructive sleep apnea (OSA) is a serious and prevalent medical condition with major consequences for health and safety. Excessive daytime sleepiness (EDS) is a common\u2014but not universal\u2014accompanying symptom. The purpose of this literature analysis is to understand whether the presence/absence of EDS is associated with different physiopathologic, prognostic, and therapeutic outcomes in OSA patients. Methods: Articles in English published in PubMed, Medline, and EMBASE between January 2000 and June 2017, focusing on no-EDS OSA patients, were critically reviewed. Results: A relevant percentage of OSA patients do not complain of EDS. EDS is a significant and independent predictor of incident cardiovascular disease (CVD) and is associated with all-cause mortality and an increased risk of metabolic syndrome and diabetes. Male gender, younger age, high body mass index, are predictors of EDS. The positive effects of nasal continuous positive airway pressure (CPAP) therapy on blood pressure, insulin resistance, fatal and non-fatal CVD, and endothelial dysfunction risk factors have been demonstrated in EDS-OSA patients, but results are inconsistent in no-EDS patients. The most sustainable cause of EDS is nocturnal hypoxemia and alterations of sleep architecture, including sleep fragmentation. These changes are less evident in no-EDS patients that seem less susceptible to the cortical effects of apneas. Conclusions: There is no consensus if we should consider OSA as a single disease with different phenotypes with or without EDS, or if there are different diseases with different genetic/epigenetic determinants, pathogenic mechanisms, prognosis, and treatment.The small number of studies focused on this issue indicates the need for further research in this area. Clinicians must carefully assess the presence or absence of EDS and decide accordingly the treatment. This approach could improve combination therapy targeted to a patient\u2019s specific pathology to enhance both efficacy and long-term adherence to OSA treatment and significantly reduce the social, economic, and health negative impact of OSA

Breathing Re-Education and Phenotypes of Sleep Apnea: a Review

Four phenotypes of obstructive sleep apnea hypopnea syndrome (OSAHS) have been identified. Only one of these is anatomical. As such, anatomically based treatments for OSAHS may not fully resolve the condition. Equally, compliance and uptake of gold-standard treatments is inadequate. This has led to interest in novel therapies that provide the basis for personalized treatment protocols. This review examines each of the four phenotypes of OSAHS and explores how these could be targeted using breathing re-education from three dimensions of functional breathing: biochemical, biomechanical and resonant frequency. Breathing re-education and myofunctional therapy may be helpful for patients across all four phenotypes of OSAHS. More research is urgently needed to investigate the therapeutic benefits of restoring nasal breathing and functional breathing patterns across all three dimensions in order to provide a treatment approach that is tailored to the individual patient

Obstructive Sleep Apnea in Young Infants with Down Syndrome Evaluated in a Down Syndrome Specialty Clinic

Children with Down syndrome (DS) experience congenital and functional medical issues that predispose them to obstructive sleep apnea (OSA). Research utilizing stringent age criteria among samples of infants with DS and OSA is limited. This study examines clinical correlates of OSA among infants with DS. A retrospective chart review was conducted of infants ≤6 months of age referred to a DS clinic at a tertiary children's hospital over five-years (n = 177). Chi-square tests and binary logistic regression models were utilized to analyze the data. Fifty-nine infants underwent polysomnography, based on clinical concerns. Of these, 95% (56/59) had studies consistent with OSA. Among infants with OSA, 71% were identified as having severe OSA (40/56). The minimum overall prevalence of OSA among the larger group of infants was 31% (56/177). Significant relationships were found between OSA and dysphagia, congenital heart disease (CHD), prematurity, gastroesophageal reflux disease (GERD), and other functional and anatomic gastrointestinal (GI) conditions. Results indicate that odds of OSA in this group are higher among infants with GI conditions in comparison to those without. Co-occurring dysphagia and CHD predicted the occurrence of OSA in 36% of cases with an overall predictive accuracy rate of 71%. Obstructive sleep apnea is relatively common in young infants with DS and often severe. Medical factors including GI conditions, dysphagia and CHD may help to identify infants who are at greater risk and may warrant evaluation. Further studies are needed to assess the impact of OSA in infants with DS

Long-term CPAP use in obstructive sleep apnea : Effects on cardiovascular outcomes, weight control and motor vehicle accidents

Obstructive sleep apnea (OSA) is a common disorder associated with various adverse health effects, including an increased risk of cardiovascular disease (CVD) events, metabolic dysregulation, and motor vehicle accidents (MVA). This study evaluated the long-term effects of continuous positive airway pressure (CPAP), the primary treatment for OSA, in a large retrospective cohort of 1030 CPAP-adherent patients and 1030 controls matched for age, gender and apnea-hypopnea index (AHI). Controls had discontinued CPAP treatment despite their doctor’s advice. Approximately one half of the patients commencing CPAP had continued the treatment for 5 years, generally with good short- and long-term adherence. Only a weak positive correlation was found between AHI and long-term CPAP usage, while no association could be verified between AHI and the risk of CVDs or MVAs. CPAP-treated patients at the cohort level had a slight weight gain at a comparable rate to that observed in the general middle-aged Finnish population, while 10 % of the patients at the individual level had a significant weight gain. Those individuals, at baseline, were already more severely obese despite being younger than the rest of the cohort. An association between CPAP and a reduced risk of CVDs and all-cause mortality, in comparison to controls, was observed over a median follow-up of 9 years but only among those with CPAP use of >4–6 h/day. The incidence of MVAs did not change when compared 9 years before and after treatment or in CPAP-treated patients and controls regardless of the level of adherence. The results of the present study emphasize that OSA is a heterogeneous disease, and the use of AHI alone is insufficient to assess OSA severity or to identify highrisk patients for adverse outcomes. The results further imply that CPAP use of >4–6 h/day is needed to achieve potential improvements in CVD risk. Patients are more likely to gain than lose weight during CPAP treatment, underlying the urge for lifestyle interventions. The incidence of MVAs did not change after CPAP use, suggesting that the MVA risk is likely to be multifactorial, and even longer observation periods may be needed to detect a significant difference.Pitkäaikainen CPAP-hoito uniapneapotilailla: vaikutukset sydän- ja verisuonitautisairastavuuteen, painonhallintaan ja liikenneonnettomuusalttiuteen Obstruktiivinen uniapnea on yleinen sairaus, johon liittyy vakavia terveysriskejä, kuten sydän- ja verisuonisairaudet, aineenvaihdunnan toimintahäiriöt ja suurentunut liikenneonnettomuusalttius. Tämä tutkimus kartoitti takautuvasti obstruktiivisen uniapnean ensisijaisen hoitomuodon, ylipaine- eli CPAP-hoidon vaikuttavuutta. Tutkimuksessa oli mukana 1030 pitkäaikaisesti hoitoon sitoutunutta potilasta ja 1030 iän, sukupuolen ja apnea-hypopneaindeksin (AHI) suhteen kaltaistettua verrokkia, jotka olivat lopettaneet CPAP-hoidon lääkärin suosituksesta huolimatta. Keskimäärin puolet hoidon aloittaneista oli jatkanut hoitoa >-5 vuotta. Hoitoon sitoutuminen oli hyvällä tasolla sekä lyhyt- että pitkäaikaisesti. Heikko tilastollinen vastaavuus havaittiin AHI:n ja pitkäaikaisten käyttötuntien välillä, mutta yhteyttä AHI:n ja sydän- ja verisuonitautisairastavuuden tai liikenneonnettomuusriskin välillä ei todettu. Ryhmätasolla havaittiin vähäinen painonnousu, joka oli vastaava kuin suomalaisessa keski-ikäisessä väestössä yleensä. Yksilötasolla 10 % potilaista lihoi merkittävästi. Nuoremmasta iästään huolimatta he olivat jo lähtötilanteessa vaikeammin lihavia kuin muut tutkimuspotilaat. Verrokkiryhmään verrattuna CPAP-hoidon käyttö >4–6 tuntia päivässä liittyi pienempään sydän- ja verisuonitautisairastavuuteen ja kokonaiskuolleisuuteen 9 vuoden seuranta-aikana. Liikenneonnettomuuksien esiintyvyys ei muuttunut, kun potilaita verrattiin 9 vuotta ennen ja jälkeen hoidon, käyttötuntien perusteella tai suhteessa verrokkipotilaisiin. Tulosten perusteella obstruktiivinen uniapnea on monimuotoinen sairaus, jonka vaikeusastetta ei voida luotettavasti arvioida eikä suurimmassa terveysriskissä olevia tunnistaa pelkän AHI:n perusteella. Mahdollinen suotuisa vaikutus sydän- ja verisuonitautisairastavuuteen edellyttänee CPAP-hoidon käyttöä >4–6 tuntia päivässä. Lihominen hoidon aikana on todennäköisempää kuin laihtuminen painottaen elintapahoitojen tärkeyttä. Liikenneonnettomuuksien esiintyvyys ei muuttunut CPAP-hoidon myötä. Liikenneonnettomuuteen joutuminen on todennäköisesti monitekijäinen tapahtuma ja pidempi seuranta-aika saattaa olla tarpeen, jotta merkittävä ero voitaisiin havaita

Defining obstructive sleep apnoea syndrome: a failure of semantic rules

Obstructive sleep apnoea syndrome (OSAS) is one of the most ubiquitous medical conditions in industrialised society. Since the recognition that symptoms of excessive daytime somnolence, problems with concentration, mood and cognitive impairment, as well as cardiometabolic abnormalities can arise as a consequence of obstructed breathing during sleep, it has been subject to variation in its definition. Over the past five decades, attempts have been made to standardise the definitions and scoring criteria used for apnoeas and hypopnoea, which are the hallmarks of obstructive sleep apnoea (OSA). However, applying these definitions in clinical and research practice has resulted in over- and under-estimation of the severity and prevalence of OSAS. Furthermore, the definitions may eventually become redundant in the context of rapid technological advances in breathing measurement and other signal acquisition. Increased efforts towards precision medicine have led to a focus on the pathophysiology of obstructed breathing during sleep. However, the same degree of effort has not been focused on how and why the latter does or does not result in diurnal symptoms, integral to the definition of OSAS. This review focuses on OSAS in adults and discusses some of the difficulties with current definitions and the possible reasons behind them

SURGICAL AND NON-SURGICAL THERAPY OF OBSTRUCTIVE SLEEP APNEA SYNDROME IN CHILDREN.

Interventions of paediatric obstructive sleep apnea syndrome are complex, varied and multidisciplinary. The goal of the treatment is to restore optimal breathing during the night and to relieve associated symptoms. Evidence suggests that the surgical intervention with removal of the tonsils and adenoids will lead to significant improvements in the most incomplicated cases, as recently reported from a meta-analysis. However, post-operative persistence of this syndrome in paediatric population is more frequent than expected, which supports the idea of the complexity of this syndrome. Adenotomy alone may not be sufficient in children with OSAS, because it does not address oropharyngeal obstruction secondary to tonsillar hyperplasia. Continuous positive airway pressure can effectively treat this syndrome in selected groups of children, improving both nocturnal and daytime symptoms, but poor adherence is a limiting factor. For this reason, CPAP is not recommended as first-line therapy for OSAS when adenotonsillectomy is an option. It is now being investigated the incorporation of nonsurgical approaches for milder forms and for residual OSAS after surgical intervention. Althought adeno­tonsillar hypertrophy is the most common for OSAS in children; obesity is emerging as an equally important etiological factor. Therefore an intensive weight reduction program and adequate sleep hygiene are also important lifestyle changes that may be very effective in mitigating the symptoms of this syndrome. Pharmacological therapy (leukotriene antagonists, topical nasal steroids) is usually use for mild forms of OSAS and in children with associated allergic diseases. Special orthodontic treatment and oropharyngeal exercises are a relatively new and promising alternative therapeutic modality used in selected groups of children with OSAS