Additional Info on Myofunctional

Did you know that the way your child breathes can affect the development of his or her jaws and facial structure influencing how the teeth fit together? Normal breathing should occur through the nose with the mouth closed. However, if the nasal passage is somehow obstructed, mouth breathing often results.

Generally, nasal airway obstruction is caused by one or more of the following:

• Enlarged adenoids
• Nasal blockage due to swollen tissue, allergies or polyps
• Underdeveloped nasal passages and/or underdeveloped jaw and cheekbones
• Deviated nasal septum

All of the above can cause the child to breathe with his or her mouth open. This open-mouth posture causes the facial muscles to generate unnatural constrictive forces on the underlying bony structures (see figure 2A). Narrowing and elongation of the upper jaw often is the result of such forces (see figure 2B). In addition, the jaws tend to grow apart, often causing front open bites, which affect the position of the tongue and other facial structures. Also, because the lower jaw is dropped for mouth breathing, it tends not only to grow apart from the upper jaw but also becomes positioned further back than normal, causing an overbite.

How the tongue rests in the mouth can also negatively affect facial growth. The tongue at rest should be high in the mouth, which stimulates normal growth of the maxilla (upper jaw). Habits such as thumb sucking, bottle feeding or the use of dummies past the age of 3 years force the tongue in a downward position, resulting in an open mouth posture, narrow dental arches, and possibly an open bite in the front. This in turn can contribute to prognathism (protruding lower jaw) by overstimulating jaw growth.

The following is a list of symptoms associated with airway obstruction:

• Open mouth position (with possible open bite)
• Narrow arches
• Short upper lip
• Prominent upper incisors
• V-shaped maxilla, high palatal vault
• Pouting lower lip
• Chronic chapped or cracked lips
• Tongue held in low mouth position
• Gummy smile and red swollen gum tissue
• Allergic shiners (constant dark circles under the eyes)
• Excessive snoring at night

85% of orofacial growth is accomplished by the age of twelve. Therefore, early identification of airway interferences, with a diagnosis of the underlying cause, is essential to prevent orofacial growth abnormalities. If you, your dentist, dental hygienist, or paediatrician observe any of the above symptoms and suspect possible airway obstruction in your child, evaluation by an ENT physician should be undertaken.

Please keep in mind that many other factors can affect dental-facial development (i.e. genetics, muscular tone, tooth & jaw sizes, etc). Therefore addressing just these airway interferences will not always guarantee the correction of dentofacial problems. However, if airway interferences are eliminated before facial growth is completed, a suitable environment will be established to promote more normal development. This can eliminate or simplify the need for extensive orthodontic treatment, and relapse of orthodontic treatment is greatly reduced. The results include not only a more stable dentition and bite but also a more pleasing facial appearance for your child.

The following professional references have been provided for your paediatrician/physician if they would like to know more about the effects of airway obstruction upon facial growth.

McNamara: Naso-respiratory function and craniofacial growth, centre for human growth and development, Ann Arbor, MI, 1979.
Linder-Aronson, Woodside & Lundstrom: Mandibular growth direction following adenoidectomy, Am J Ortho and Dentofacial Orthop, April 1986.
Shapiro: The Effects of nasal obstruction on facial development and orthodontic treatment, office of continuing education, Baylor College 1987
Meredith: The airway and dentofacial development, ENT J 1987
Weimert, Thomas: Evaluation of the upper airway in children, ENT J 1987
Richter, Harry: Obstruction of the pediatric upper airway, ENT J 1987
Gray, Lindsay: Rapid maxillary expansion and impaired nasal respiration, ENT J 1987
Timms: Rapid maxillary expansion in the treatment of nasal obstruction and respiratory disease, ENT J 1987

Paediatric sleep apnea is a sleep disorder characterized by obstructed or narrowed respiration while a child sleeps. The condition affects an estimated 25% of children in the US and typically occurs between ages 2 and 8, though it is quite underdiagnosed. Pauses in breathing during sleep in patients with paediatric sleep apnea are typically much shorter and lighter than those in adults with sleep apnea. While an adult may snore loudly and make choking noises, a child may simply stop breathing momentarily and then wake up. Both conditions can lead to sleep deprivation and a wealth of other health issues if left untreated.

Children with paediatric sleep apnea often suffer from symptoms such as restlessness and bed-wetting. Parents may notice that their kids tend to snore or breathe irregularly through their mouths. During the day, children may seem tired and inattentive as a result of poor sleep the night before. Daytime symptoms of paediatric sleep apnea can also include hyperactivity and mood swings. The majority of paediatric sleep apnea patients have enlarged tonsils and adenoids, which physically block the child’s upper airway. Usually, a minor surgical procedure to have the tonsils and/or adenoids removed will cure the condition. However, other conditions may cause sleep apnea in young children, such as physical deformities or muscle weakness. Obese children and children with thicker necks are much more prone to paediatric sleep apnea.

Finding immediate treatment for paediatric sleep apnea is perhaps even more important than for older patients. Paediatric sleep apnea that starts at such an early stage can stunt growth and lead to several developmental issues. Over time, if a child is not getting enough quality sleep, he or she does not acquire sufficient amounts of oxygen to aid in normal brain and body development.

The child is more likely to be diagnosed later in life with health conditions like attention-deficit hyperactivity disorder (ADHD) and childhood obesity. Patients who grow up with untreated, chronic sleep apnea are also more likely to have learning disabilities, behavioural problems and metabolic problems.

In addition to making sure your child maintains proper diet and exercise, it is crucial that parents who notice symptoms of paediatric sleep apnea in their kids go to visit a primary care physician or a sleep centre for further information. A sleep doctor can perform an overnight test called a polysomnography, which allows specialists to observe behaviour, breathing and vital functions while the child sleeps in a sleep lab room. Data collected overnight will lead to the proper diagnosis of the child’s sleep disorder so that the child can move forward with treatment either with a CPAP machine, oral appliances or surgery. As children aren’t able to identify the problem on their own, parents must pay close attention to their children’s sleep habits and daytime behaviour. In the event of any irregularity in breathing, be sure to visit a sleep doctor as soon as possible.

(source: www.sleepdisorders.com)

Sleep disordered breathing (SDB) is common in childhood. Epidemiologic data have shown that snoring and tooth grinding occurs in 7-30% of school-aged children. Of the group of snorers, about 20% will have the more severe forms of Obstructive Sleep Apnea (OSA). Grinding, jaw clenching, and snoring have been associated with OSA in children. The most common cause of OSA in children is enlarged tonsils or adenoids, leading to obstructed airways, forcing the child to bring the lower jaw forward to open up airways (called “mandibular thrusting”). Children with even the mildest form of SDB will experience frequent nighttime arousals, with disrupted sleep and altered daytime functioning. Symptoms of untreated SDB may include excessive daytime sleepiness, failure to thrive, bed wetting, behavioural problems, and in more advanced cases, cardiac complications.
Dental signs of SDB are extreme wear on the dentition, evidence of cheek biting, narrow arch development and abnormal tongue swallow patterns.

As shown in many studies, a large number of children with Attention Deficit Hyperactivity Disorder (ADHD) or inattentive behaviours were later shown to have an underlying sleep-disordered breathing problem. It is a distinct possibility that if more attention were paid to the underlying sleep issues there would be less reliance on stimulant medications to manage their behaviour.

Does your child have any of the following symptoms?

• Continuous loud snoring
• Episodes of not breathing at night (apnea)
• Failure to thrive (weight loss or poor weight gain)
• Chronic mouth breathing
• Enlarged tonsils and adenoids (with frequent sore throat infections)
• Problems sleeping, bed wetting and restless sleep (including sleepwalking)
• Excessive daytime sleepiness
• Frequent headaches

Daytime cognitive and behaviour problems, including problems paying attention, aggressive behaviour and hyperactivity, which can lead to problems at school.

(sources: Dental Sleep Medicine; Singapore Med J 2002; Sleep 2004; Am Fam Physician 2004; Am J Respir Crit Care Med 2002; Sleep Res 2006; Pediatrics 2004)

Diagnoses of ADHD among children have increased dramatically in recent years, rising 22% from 2003 to 2007, according to the CDC. But many experts believe that this may not be the epidemic it appears to be. Many children are given a diagnosis of ADHD, researchers say, when in fact they have another problem: a sleep disorder, like sleep apnea. The confusion may account for a significant number of ADHD cases in children, and the drugs used to treat them may only be exacerbating the problem. The symptoms of sleep deprivation in children resemble those of ADHD. While adults experience sleep deprivation as drowsiness and sluggishness, sleepless children often become wired, moody and obstinate; they may have trouble focusing, sitting still and getting along with peers.

The latest study “Sleep-Disordered Breathing in a Population-Based Cohort: Behavioural Outcomes at 4 and 7 years” suggests a link between inadequate sleep and ADHD symptoms appeared in 2012 in the journal Pediatrics. Researchers followed 11,000 British children for six years, starting when they were 6 months old. The children whose sleep was affected by breathing problems like snoring, mouth breathing or apnea were 40% to 100% more likely than normal breathers to develop behavioural problems resembling ADHD.

Children at the highest risk of developing ADHD-like behaviours had sleep-disordered breathing that persisted throughout the study but was most severe at age 2 1/2.

“Lack of sleep is an insult to a child’s developing body and mind that can have a huge impact,” said Karen Bonuck, the study’s lead author and a professor of family and social medicine at Albert Einstein College of Medicine in New York. “It’s incredible that we don’t screen for sleep problems the way we screen for vision and hearing problems.”

Source: New York Times Health

In 2011 the American Academy of Paediatrics (www.aap.org) published a policy statement reiterating its recommendation that infants should be breastfed exclusively for 6 months. They also made this recommendation in their 2005 paper, but this time they quantify the health benefits. The authors wrote that others have suggested that more than 900 infant deaths per year in the United States could be prevented if 90% of mothers breastfeed exclusively for six months. They also cited evidence that breastfeeding improves neurodevelopmental outcomes and enhances the development of host defences in infants born preterm.

Other benefits include the following:

• 72% reduction in hospitalization for respiratory infections
• 64% reduction in the incidence of gastrointestinal infections
• 58% to 77% reduction in the incidence of necrotizing enterocolitis
• 36% to 45% reduction in the risk of sudden infant death syndrome
• 27% to 42% reduction in the incidence of asthma, atopic dermatitis, and eczema
• 52% reduction in the risk of celiac disease
• 31% reduction in the risk of inflammatory bowel disease
• 15% to 30% reduction in the incidence of obesity in adolescents and adulthood
• 15% to 20% reduction in the risk of childhood leukaemia and lymphoma.

Please also note that bottle-feeding increases the risk of dental crowding and malocclusion. The smaller your jaws, the less airway you’ll have to breathe through properly during the day and especially at night. Notice that sleep-related breathing problems can directly or indirectly influence most, if not all the bullets listed above. It’s also important to note that the physical act of breastfeeding itself is what protects against dental crowding and an increased risk of developing obstructive sleep apnoea later in life. Exclusive breastfeeding without pumping is not practical or realistic in our society. However, you have to think about these implications.