Childhood Behavior, Academic Performance, and Sleep Apnea: The Dentist’s Role in the Diagnosis and Management of These Conditions

Most psychiatrists cannot differentiate between attention disorders (ADD, ADHD, etc) and sleep disruption or sleep disorders like sleep apnea. If you have concerns with your child’s attention or performance in school, it is critical to involve a Pediatric Ear Nose and Throat specialist (ENT), allergist, and dentist like Dr. Dulac trained in sleep medicine and the evaluation of the airway and childhood growth and development.

Sleep apnea is the disruption of breathing during sleep. In adults, it is characterized by 5 or more sleep disrupted breathing events of 10s or more per hour. This breathing disruption leads to a decrease in oxygen and a long list of associated problems in adults including:  high blood pressure, stroke, cancer, diabetes, etc. In children, sleep apnea is characterized by only 0.5 sleep disrupted events per hour. So if your child is sleeping 10-12 hours, airway disruption might only be occurring 5-6 times per night, rather than 5 times per hour in an adult. 

Children with sleep apnea have problems including bed wetting, irritability, attention deficit disorders and behavioral problems.  Children who snore and have sleep apnea usually do poorly in school. The child is overtired and thus cannot focus or concentrate in class or may fall asleep in class. Additionally, the sleep disruption leads to decreased conversion from short to long-term memory that occurs during sleep.  Children with sleep apnea have trouble attaining and sustaining stage 3 sleep, known as deep restorative sleep, or stage 4 Rapid Eye Movement (REM) sleep. A reduction in deep sleep also results in less production and release of growth hormones, resulting in growth delays.  

The diagnosis of sleep apnea is done with a sleep study.  Dr Dulac has home sleep tests (Watchpat) approved for children age 12 and older (or 65 lbs and above). Ideally, we would like to catch these issues younger, around age 5. A home sleep study would not be suitable for a child of that age and would take place in a hospital or sleep clinic.

The most common cause of snoring and sleep apnea in children is enlarged tonsils and adenoids.  Enlarged tonsils and adenoids can be caused by allergies, so I recommend involving an allergist. Enlarged tonsils and adenoids can also be caused by mouth breathing, so I recommend involving a dental professional. The removal of enlarged tonsils or adenoids would be done surgically by a pediatric ENT. 

Mouth breathing is commonly caused by abnormal development of the jaws. An underdeveloped upper jaw results in poor nasal breathing, and thus poorer oxygenation. We get 20% more oxygen through nasal breathing than mouth breathing. The roof of the mouth is the floor of the nose; so children with an underdeveloped upper jaw have an underdeveloped nasal airway and children with a high palatal vault are more prone to having a deviated septum.

In addition to nasal development, properly sized jaws are also critical for tongue space.  Without a place for the tongue to go in properly sized upper and lower jaws, the tongue can block the airway, resulting in snoring and sleep apnea. And a “tongue tie” (prominent lingual frenum) also restricts the tongue from proper positioning.

The management of the growth and development of the jaw and tongue space should be done by a dentist like Dr Dulac, or a pediatric dentist or orthodontist with proper childhood sleep training.  The dental treatment for these children is proper upper and lower arch development using functional dental appliances that will expand their jaws, properly position the lower jaw, allow for space for the tongue, and encourage normal nasal breathing.  Additionally, if a tongue tie is observed, Dr Dulac will recommend and perform a procedure known as a frenectomy to relieve the tongue tie.

Although this treatment is best done in children, this treatment can be done for patients of any age once the problem is identified. If you would like to schedule a consultation with Dr Dulac for yourself or your child, please contact the office today!

For further information on this topic, I recommend the book GASP by Dr Michael Gleb, or Tongue Tied by Dr Richard Baxter.  A list of references in the scientific literature is also included below.

References:

SIGNS OF AIRWAY OBSTRUCTION DURING SLEEP AND BEHAVIORAL, DEVELOPMENTAL, AND ACADEMIC PROBLEMS. WEISSBLUTH M, DAVIS AT, PONCHER J, REIFF J. J DEV BEHAV PEDIATR 1983;4(2):119-121.

COULD MOUTH BREATHING LEAD TO OBSTRUCTIVE APNEA SYNDROME? A PRELIMINARY STUDY RASKIN S, LIMME M, POIRRIER R. ORTHOD FR 2000;71(1):27-35.

HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH SLEEP-DISORDERED BREATHING: EFFECT OF MANDIBULAR ADVANCEMENT APPLIANCES. JOHAL A. J PROSTHET DENT 2006; 96(4):298-302

THE EFFECT OF 1-YEAR TREATMENT WITH HERBST MANDIBULAR ADVANCEMENT SPLINT ON OBSTRUCTIVE SLEEP APNEA, OXIDATIVE STRESS, AND ENDOTHELIAL FUNCTION. ITZHAKI S, DORCHIN H, CLARK G, LAVIE L, LAVIE P, PILLAR G. CHEST 2007;131(3):740-749.

A COMPARISON OF THE TWIN BLOCK AND HERBST MANDIBULAR ADVANCEMENT SPLINTS IN THE TREATMENT OF PATIENTS WITH OBSTRUCTIVE SLEEP APNEA: A PROSPECTIVE STUDY. LAWTON HM, BATTAGEL JM, KOTECHA B. EUR J ORTHOD 2005;27 (1):82-90.