Dr. Steven Olmos talks about skeletal deficiency and how treatment can result in improved breathing, and reduction of facial pain, headaches, and bruxism.
Obstructive sleep apnea (OSA) and chronic facial pain are highly comorbid and common. In the United States and throughout the world, the prevalence of OSA is increasing.1 Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA.2 OSA is widely underdiagnosed — 86% to 95% of individuals found in population surveys with clinically significant OSA report no prior OSA diagnosis.3 OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure (HF), coronary artery disease, pulmonary hypertension (PH), atrial fibrillation (AF), and stroke.4
One in six adults who visited a general dentist during 2015 experienced chronic facial pain. Pain in the muscles and temporomandibular joints was reported as frequently as that in the teeth and surrounding tissues in patients visiting general dentists.5 A meta-analysis of world literature has found that one in six children and adolescents has clinical signs of temporomandibular joint (TMJ) disorders.6 Over 23% of preschool-aged children have pain when chewing and jaw joint noises.7 All jaw joint noises are pathologic.
An established relationship exists between OSA and TMD that is evident in the prevalence rates that are bidirectional. There is an increased prevalence of TMD in patients diagnosed with OSA.8 There is an increased prevalence of OSA in patients diagnosed with TMD.9 Two studies10 tested the hypothesis that OSA signs and symptoms were associated with TMD: The Orofacial Pain Prospective Evaluation and Risk Assessment Study (OPPERA) prospective cohort study of adults aged 18 to 44 years at enrollment (n 2604) and The OPPERA case — control study of chronic TMD (n 1716). Both studies supported a significant association between OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first onset of TMD. Patients with two or more signs and/or symptoms of OSA had a 73% greater incidence of first-onset TMD.
Nasal obstruction that results in mouth breathing has recently been found to be highly comorbid with chronic facial pain. A study of almost 1,400 patients that has been accepted for publication (General Dentistry) found that patients with nasal valve compromise had a 7 times greater risk of facial pain. Nasal valve compromise is the result of an undeveloped maxilla. A recent study showed that maxillary expansion resulted in improved internal nasal valve and obstructive nasal symptoms in children evaluated by Nasal Obstruction Symptom Evaluation (NOSE) scores.11
Forward Head Posture (FHP) has also been found to be related to bruxism and nasal obstruction in children. “Bruxism seems to be related to altered natural head posture and more intense dental wear. A more anterior and downward head tilt was found in the bruxist group, with statistically significant differences compared to controls.”12 Bruxism in children has been found to be related to RERA and OSA.13 Expansion of the maxilla in mouth-breathing children restores proper nasal breathing and uprights the head.14,15 Surgical retrusion of the mandible in prognathic conditions results in significant FHP, perhaps in defense of a compromised oropharyngeal airway.16
Children diagnosed with migraine are 8.25 times more likely to have a sleep-breathing disorder, whereas children diagnosed with chronic tension-type headache are 15.23 times more likely to have a sleep-breathing disorder.17 Breathing disorders worsen with time. We must screen every child currently in orthodontic/orthopedic care, and those that are in need of such care. The BEARS screening tool or the validated Pediatric Screening Questionnaire (PSQ) are excellent for this purpose. The question that we are left with is, What are we treating to? The answer to that was given to us by the seminal figure in pediatric sleep medicine, Dr. Christian Guilleminault (Stanford).
He states, “Elimination of oral breathing, i.e., restoration or nasal breathing during wake and sleep, may be the only valid end point when treating OSA.”18 Treatment for skeletal deficiency (orthopedic/orthodontic development), will result in improved breathing, reduction of facial pain, headaches, and bruxism. Dentofacial orthopedics started as early as possible is the key to improving quality of life.
Skeletal deficiency played a role in treatment for this patient in Dr. Olmos’ article “Improving quality of life and faces nonsurgically.” Read it at https://orthopracticeus.com/ce-articles/improving-quality-life-faces-nonsurgically/.
- Lam JC, Sharma SK, Lam B. Obstructive sleep apnoea: definitions, epidemiology & natural history. Indian J Med Res. 2010; 131:165-170.
- Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014.
- Chen X, Wang R, Zee P, et al. Racial/ethnic differences in sleep disturbances: the Multi-Ethnic Study of Atherosclerosis (MESA). Sleep. 2015;38:877-888.
- Javaheri S, Barbe F, Campos-Rodriguez F, et al. Sleep apnea: types, mechanisms, and clinical cardiovascular consequences. J Am Coll Cardiol. 2017;21;69(7):841-858.
- Horst OV, Cunha-Cruz J, Zhou L, et al. Prevalence of pain in the orofacial regions in patients visiting general dentists in the Northwest Practice-based Research Collaborative in Evidence-based Dentistry research network. J Am Dent Assoc. 2015;146(10):721.e3 -728.e3.
- da Silva CG, Pacheˆco-Pereira C, Porporatti AL, et al. The prevalence of temporomandibular disorders in children and adolescents J Am Dent Assoc. 2016;147(1):10.e8 -18.e8.
- Ingelhart MR, Patel MH, Wideman SE, Briskie DM. Self-reported temporomandibular joint disorder symptoms, oral health, and quality of life of children in kindergarten through grade 5. J Am Dent Assoc. 2016;147(2):131-141.
- Cunali PA, Almeida FR, Santos CD, et al. Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy. J Orofac Pain. 2009;23(4):339-344.
- Smith MR, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32(6):779-790.
- Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. 2013; 92:70S-77S.
- Yoon A, Abdelwahab M, Liu S, Oh J. et al. Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children. Sleep Breath. 2021;25(2):1019-1027.
- Velz AL, Restrepo CC, Pelaez-Vargas A, et al. Head posture and dental wear evaluation of bruxist children with primary teeth. J Oral Rehabil. 2007;34(9)ß:663-670
- Ferreira NM, dos Santos JF, dos Santos MB, Marchini L. Sleep bruxism associated with obstructive sleep apnea syndrome in children. Cranio. 2015;33(4):251-255.
- Tecco S, Festa F, Tete S, Longhi V, D’Attilo. Changes in head posture after rapid maxillary expansion in mouth-breathing girls: a controlled study. Angle Orthod. 2005;75(2):171-176
- McGuinness NJ, McDonald JP. Changes in natural head position observed immediately and one year after rapid maxillary expansion. Eur J Orthod. 2006;28(2):126-134.
- Cho D, Choi D, Jang I, Cha BK. Changes in natural head position after orthognathic surgery in skeletal class III patients. Am J Orthod Dentofacial Orthop. 2015;147(6):747-754.
- Carotenuto M, Ruju F, Pascotto A, et al. Headache disorders as risk factors for sleep disturbances in school aged children. Headache Pain 2005;6(4):268-270.
- Guilleminault C, Sullivan SS. Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Enliven Pediatric Neonatol Biol. 2014;1(1):001.