Sleep-Related Breathing Disorders.
Comment by Dr Noel Stimson, editor of Cranio UK, the journal of the British Society for the Study of Cranio-Mandibular Disorders – http://www.jawache.com
In recent years there has been much debate about sleep-related breathing disorders (SRBD) and whether or not dentists and, in particular, orthodontists, should get involved. Critics have pointed out that there is little scientific evidence to support such involvement, added to which, most dentists will simply see it as an opportunity to make money!
The critics are wrong in both their presumptions, especially about the evidence. Given the fact that this is a relatively recent development in dentistry, the available evidence has impressed the American Dental Association to the degree that in March 2017 the ADA issued a “Proposed Policy Statement on the Role of Dentistry in the Treatment of Sleep Related Breathing Disorders” (see the ADA website for the full text), ratified in Congress in October 2017. This document makes it clear that, while the diagnosis and management of sleep disorders are fundamentally medical issues, for many sleep disorder patients, especially children, dentists and orthodontists have within their skill set possibly the most effective treatment solution in the form of appropriate oral appliances. The ADA is also clear that while CPAP is usually the treatment of choice for Obstructive Sleep Apnoea, there is a high level of non- compliance, especially among younger patients. This explains why oral appliances are deemed more effective overall.
The ADA Policy Document states that “dentists can and do play an essential role in the disciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients at risk of SRBD”. The document goes on to state that “SRBD can be caused by a number of multifactorial medical issues and are therefore best treated through a collaborative model”, and “the dentist’s recognition of sub-optimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopaedic intervention”. The dentist’s role in the treatment of SRBD, with special emphasis on sleep apnoea, is summarised by the ADA as follows: 1.Patient screening and appropriate referral to physicians. 2.To identify signs and symptoms of poor craniofacial growth and development. 3.Provision of appliance therapy, if deemed appropriate by the dentist, to be monitored and adjusted as required by the dentist. 4. Referral for surgery if appliance therapy is deemed inadequate. 5.To continue to update their knowledge of dental sleep medicine. 6. To maintain regular communication with the referring physician and to arrange follow-up sleep testing to evaluate improvement.
The dentists among us will all be aware of the signs of potential sleep problems for children such as dysfunctional swallowing, mouth breathing, tongue-tie, inadequate maxillary development, tendency for vertical facial growth and head-forward posture – all matters that would become far more apparent to a dentist on the basis of a twice- yearly check up than they would to a physician. So why are these kinds of sleep disorders viewed as fundamentally medical issues, when it is the dentist who can screen, diagnose,treat, monitor and refer for sleep investigations when required?
Of even more concern for us in the UK is there is effectively no mention of sleep related breathing disorders on the websites of either the British Dental Association or General Dental Council? Where does that leave us? The advice on Kevin O’Brien’s blog is that as he considers there is no acceptable science to support the dental sleep medicine view, then we cannot claim to treat these disorders; all we need to do, we are told, is refer for removal of the officially-regarded most common cause of obstruction, tonsils and adenoids! If we do embark on an orthodontic approach, all we can say is, according to the O’Brien view, “let’s see if straightening your teeth improves your nocturnal breathing” as if straight teeth was the only issue. They are not, of course; to quote Barry Raphael, “the teeth are simply an expression of the same deficiency – small jaws and an impaired airway”.
They do, however, make excellent handles for us to take hold of to solve the airway problems. If straighter teeth are the result, then we have all made a gain. The crucial point is that breathing disorders can have serious health implications; not so crooked teeth.
Problems which can arise from Deviated facial alignment
FACE – Foundation for Airway and Craniofacial Excellence
FACE was founded by Julia Worrall, RN, CCRN in Toronto, Canada. Julia was a long-time critical care nurse who, for the past several years, has dedicated herself to learning as much as she can about how craniofacial structures affect airway and neurological function. She was brought to my attention by Michelle McManus, a dystonia patient whose symptoms have been mostly alleviated by a combination of orthodontic appliances and body therapy. Michelle is the founder of the Facebook forum ” Dystonia, TMJ and the connection”. This collaborative approach to treatment has also proved beneficial in treating conditions such as Tourette’s and Parkinsons.
See. http://www.facemedicine.org and http://www.sleepandtmjtherapy.com
Summer issue of Cranio U.K
The journal for the British Society for the Study of Cranio-Mandibular Disorders. Please email if you would like a digital copy.
New video by Dr Derek Mahony
This is a short video aimed at informing parents of the need to establish:
Good lip seal
Nasal Breathing
Correct Tongue posture
at an early age in order to maintain normal facial growth.
King’s Dental Institute, Guy’s Hospital. 8 May 2017
My third presentation to final year dental students by kind invitation of the Interim Executive Dean and Director of the Sleep Disorders Clinic at Guy’s Campus, Professor Mark Woolford, ” Exploring the Wider Role of Dentistry – The Effect of Jaw Problems on the Rest of the Body.” Two sections: Airway & Sleep Disorders, Temporo-Mandibular Joint Dysfunction and Posture. (ii) Movement Disorders.
The advantage of early correction using appliances such as the Biobloc, ALF ( Advanced Lightwire Functional), BWS (Bent Wire System) and Myobraces was also covered.
Osteopathic Centre for Children, London, SW18 7 May 2017 9th visit
My 9th presentation to postgraduate osteopaths in their final year of studying at the OCC.
“Exploring the Wider Role of Dentistry – The Effect of Jaw Problems on the Rest of the Body.” Two sections: Airway & Sleep Disorders, Temporo-Mandibular Joint Dysfunction and Posture. (ii) Movement Disorders.
The advantage of early correction using appliances such as the Biobloc, ALF ( Advanced Lightwire Functional), BWS (Bent Wire System) and Myobraces was also covered. Invited back for next year.Invited back for next year.
