d-cause and prevention of osa - brian palmer, ddsmalocclusion. Ł bottle feeding leads to a habit of...
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Cause and Prevention of OSA
� Principles involved in OSA
� Hypothesis
� Prevention
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Principles involved in airway collapse
� Vacuum
� Gravity
� Venturi principle
� Bernoulli principle
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A vacuum can create an inward collapse of the oral cavity, throat and airway.
Vacuum
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While asleep, muscles relax and gravity can drop the tongue back and block off the airway.
Jaw and tongue are forward while awake.
Gravity
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Venturi Principle
Air must pass through a small tube faster than through a large tube, if the volume of air and time to pass
through are equal.
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Bernoulli Principle
� Causes an inward collapsing of a soft tube.
� Principle used in atomizers & carburetors.
� Could cause an elongation of any stretchable material inside the tube.
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Atomizer uses Bernoulli principleD8
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Elongated palate and uvula of a 14 year old with compromised airwayD11
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Prehistoric skull with wide palate and large posterior nasal aperture. There is also good width between the pterygoid plates. This allows for a wide beginning of the airway.
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The wider the beginning of the airway, the less risk for collapse of the airway.
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Skull from the 1940s demonstrating a high palate and narrow maxillary arch. Note small nasal aperture and less width between the pterygoid plates. This results in a narrow beginning of the airway - which creates a greater risk of airway collapse.
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Close up of previous slide demonstrating narrow openingD15
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The narrower the beginning of the airway, the greater the risk for collapse.
For example, a narrow skinny straw collapses a lot easier than a wide straw when drinking a milk shake.
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Rapid palatal expansion also expands the pterygoid platesD17
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Hypothesis:Prehistoric man did not have OSA
In prehistoric skulls you rarely find:
� High palates
� Narrow arches
� Overjets
� Non pathologic malocclusions
You do find, however:
� Large posterior nasal apertures or choanae
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Prehistoric skull has good facial form, beautiful dental occlusion and no dental decay. There were no options except to breastfeed during that era.
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Classic prehistoric skull with wide palate and archD20
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Prehistoric skull with wide palate and large posterior nasal aperture.
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Classic wide prehistoric mandibular arch - has good tongue space.D22
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Modern high palate and narrow archD23
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Modern (1940) high palate / small posterior apertureD24
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Rapid palatal expansion - a fairly common orthodontic procedureD25
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Hypothesis
Breastfeeding
reduces the risk of
Obstructive Sleep Apnea
Brian Palmer, D.D.S, 2001D26
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Breastfeed babies have a better chance of having a good natural palate and arch width like this prehistoric skull.
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Ideal wide palate and nice �U� shaped arch of an adult that was breastfed.
Narrow �V� shaped maxillary arch and high palate of an adult that was bottle fed and was a thumb sucker.
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Labbok / Hendershot article:
� Principle finding - the longer the duration of breastfeeding, the lower the incidence of malocclusion.
� Bottle feeding leads to a habit of forward tongue thrusting and a weakened development of the orbicularis muscles.
� There is a significant decrease in tongue thrusting with an increased duration of breastfeeding .
Labbok M et al. Does breast-feeding protect against malocclusion? Am J Prev Med, 1987;3(4):227-32
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During breastfeeding, the proper tongue action is developedD30
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Tongue / teeth / cheeks are at rest in a �neutral� position. There are no abnormal forces within the mouth. This allows for the proper alignment of the teeth and dental arches.
This also allows for normal face development. Will discuss in another presentation on �long face syndrome�.
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While at rest, the tongue does not exert abnormal forces on any of the structures within the oral cavity. The teeth remain in astable position because they are in a �neutral zone� between the tongue and cheeks.
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During breastfeeding, the breast (breast/nipple) adapts to the shape of the mouth. The peristaltic motion of the tongue during breastfeeding, presses the breast up against the palate.
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The mouth has to adjust to any object in the mouth other than the breast. The unnatural forces that can develop can impact the position of the teeth and shape of the palate. Muscle forces always win out over bone. - e.g.- teeth will be moved.
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Bottles can impact the shape of the mouth and the action of the tongueD36
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Excessive thumb sucking can also impact oral shape and muscular action of the tongue.
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A retruded mandible can drive tongue back into throat and can block off airway. A retruded tongue can also elevate the soft palate which in turn can block off the airway and eustachian tubes.D38
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Cadaver dissection demonstrating airway, tongue position, soft palate, eustachian tubes, epiglottis and turbinates.
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Reasons for the collapse of the Oral Cavity and Airway Space
� Improper feeding - artificial bottles and nipples
� Noxious habits - pacifiers, excessive digit sucking, lip sucking, blanket sucking, etc.
� Grossly enlarged tonsils, adenoids.
� Macroglossia and ankyloglossia
� Facial-skeletal growth abnormalities
� CNS dysfunctions affecting facial muscles
� Drugs - sugar might be considered in this categoryD40
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Prevention is better than treatment!
Early diagnosis and treatment is the best prevention of
obstructive sleep apnea (OSA)
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Basic Principle
Overall health
is directly related to the
EASE OF BREATHING
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Cost of OSA on health care dollars
Conclusion: OSA patients are heavy users of health care resources 10 years prior to their diagnosis.
Ronald J. et al. Obstructive sleep apnea patients use more health care resources ten years prior to diagnosis. Sleep Research Online, 1998; 1(1):71-74. www.sro.org
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My brother had a stroke in 1995. One of the main contributing factors was his untreated obstructive sleep apnea. He needed a tracheotomy. He no longer has the tracheotomy, but he is in a long term care facility and will never get out.
This one case of untreated OSA has cost thousands of dollars to the health care industry.
Don�t let this happen to you!
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Craniofacial Development
� Largest increase occurs within the first 4 years of life.
� Is 90% complete by 12 years of age.
Shepard, J. et al. Evaluation of the Upper Airway in Patients with OSA. Sleep 1991, 14(4):361-71. (Research done at Mayo)
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AAPD Vision Statement - 1996
� �89% of youth, ages 12 - 17 years, have some occlusal disharmony.�
� �16% of youth have a severe handicapping malocclusion that requires mandatory treatment.�
Pediatr Dent, Spec Edition: Ref Manual 1995-96, 17(6).
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Malocclusion was found in 35% of 3-year-old children
- anterior open bites in 27%
- unilateral cross bites in 8%
Paunio P et al. The Finnish competence study: The effects of living conditions on sucking habits in 3-year-old Finnish children and the association between these habits and dental occlusion. Acta Odontol Scand 1993; 51(1):23-29.
Incidence of malocclusions in infants
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- Digit and dummy sucking resulted in increased
tendency to tongue thrust.
- Tongue thrust related to: open bites, overjet, and
Class II malocclusion.
- Sucking habits influence the etiology of malocclusion
Melsen B, et al., Sucking habits and their influence on swallowing pattern and prevalence of malocclusion; European J of Orthodont, 1979, 1(4):271-280.
Impact of infant sucking habits
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Stanford Morphometric Model
P = palatal height
Mx = maxillary intermolar distance
Mn = mandibular intermolar distance
OJ = overjet
NC = neck circumference
BMI = body mass index
P + (Mx - Mn) = 3 x OJ+ 3x (BMI - 25) x (NC/BMI)
�Model has clinical utility and predictive values for patients with suspected obstructive sleep apnea�
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Models demonstrating a high palate and narrow upper dental arch
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Skull demonstrates how a high palate and narrow arch results in a small posterior nasal aperture.
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Understand the significance of a high palate and what causes itD52
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Do not take out bicuspids for orthodontic reasons unless absolutely necessary - get 2nd opinionsD53
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Palatal expansion BEFORE mid line suture fusesD54
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By using rapid palatal expansion you not only get a widening of the palate, but you can also get an enlargement of the nasal cavity and a widening of the pterygoid plates - with resultant enlargement of the posterior nasal aperture as seen on this skull.
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Class II - retrognathic malocclusionD56
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Previous models positioned in a Class I occlusionD57
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Herbst appliance in the mouthD58
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Permanent Herbst appliance - age 11 1/2 yearsD59
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Macroglossia in patient with severe OSAD60
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Tongue activity and OSA
�Apnea patients exhibited greater genioglossal activity and tensor palatini EMG activity than did controls during wakefulness.�
Mezzanotte W et al. Influence of sleep onset on upper-airway muscle activity in apnea patients versus normal controls. Amer J Respir Crit Care Med, 1996 Vol 153:1880-87.
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Upper open bites caused by lower tongue thrust
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Genetics and OSA
OSA may be the result of inherited factors such as:
- abnormal tongue motor activity
Kushida C. et al. Genetics and craniofacial dysmorphism in family studies of obstructive sleep apnea, June 1996, APSS Conference, Wash, DC.
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Inherited ankyloglossia is a contributing factor to tongue thrustingD64
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Twelve year old with massive tonsilsD65
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Same patient with tonsils removedD66
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�Modern,
non-breastfeeding nurturing,
is having a negative impact
on our health and
evolutionary destiny.�
Brian Palmer, D.D.S., 1998
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There is no one ideal treatment for OSA. A tracheotomy is the only 100% cure for the condition. Nearly all current treatments have unwanted side effects. The best and cheapest form of treatment is prevention.
Breastfeeding is the best way to prevent OSA. Breastfeeding is the best and cheapest form of
health care!
Brian Palmer, D.D.S., 2001
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For Better Health !
Brian Palmer, D.D.S.
Kansas City, Missouri, USA