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Clinical-functional characteristics of children with asthma and obstructive sleep apnea overlap associated with attention deficit hyperactivity disorder: A cross-sectional study

AUTHOR=Nguyen-Ngoc-Quynh Le, Nguyen-Thi-Thanh Mai , Nguyen-Thi-Phuong Mai , Le-Quynh Chi , Le-Thi-Minh Huong , Duong-Quy Sy Clinical-functional characteristics of children with asthma and obstructive sleep apnea overlap associated with attention deficit hyperactivity disorder: A cross-sectional study Frontiers in Neurology VOL.13 2023 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.1097202

Background: Asthma and obstructive sleep apnea (OSA) are common chronic respiratory disorders in children. The relationship between asthma and OSA is bidirectional; these conditions share multiple epidemiological risk factors. Untreated OSA may cause attention deficit hyperactivity disorder (ADHD) symptoms. This study aimed to assess the prevalence of ADHD in asthmatic children with OSA and the link between asthma control and lung function of children with asthma and OSA. Methods: A total of 96 children aged 6–15 years diagnosed with asthma, according to the Global Initiative for Asthma (GINA) 2020, were enrolled in this study. All demographic data, including age, gender, body mass index, asthma control status, therapy, the Vanderbilt ADHD Diagnostic Parent Rating Scale, lung function, and exhaled nitric oxide, were collected. In addition, home respiratory polygraphy was used to identify OSA in study subjects. Results: A total of 96 patients (8.4 ± 2.4 years) were included in the present study. OSA was identified in 60.4% of asthmatic children with a mean apnea-hypopnea index (AHI) of 3.5 ± 3.0 event/h. The inattentive ADHD subtype was significantly lower in the non-OSA asthmatic group than in the OSA asthmatic group (7.9 vs. 34.5%, p < 0.05). ADHD had a higher probability of presence (OR: 3.355; 95% CI: 1.271–8.859; p < 0.05) in the OSA group (AHI >1 event/h). Children with poorly controlled asthma had a significantly high risk of OSA (83.0 vs. 17.0%, p < 0.001) than children with well-controlled asthma. Allergic rhinitis increased the odds of having OSA in patients with asthma [OR: 8.217 (95% CI: 3.216–20.996); p < 0.05]. Conclusion: The prevalence of OSA is increased among poorly controlled asthma. ADHD may have a higher prevalence in children with OSA. Therefore, prompt diagnosis of OSA will lead to an accurate asthma control strategy in patients with asthma.

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Improved Behavior and Sleep After Adenotonsillectomy in Children With Sleep-Disordered Breathing

Wei JL, Mayo MS, Smith HJ, Reese M, Weatherly RA. Improved Behavior and Sleep After Adenotonsillectomy in Children With Sleep-Disordered Breathing. Arch Otolaryngol Head Neck Surg.
2007;133(10):974–979. doi:10.1001/archotol.133.10.974

To determine changes in behavior and sleep in children before and after adenotonsillectomy for sleep-disordered breathing (SDB) using the validated Pediatric Sleep Questionnaire (PSQ) and Conners' Parent Rating Scale–Revised Short Form (CPRS-RS).

Design

Prospective, nonrandomized study.

Setting

Ambulatory surgery center affiliated with an academic medical center.

Patients
A total of 117 consecutive children (61 boys and 56 girls) (mean [SD] age, 6.5 [3.1] years) who were clinically diagnosed as having SDB and who had undergone adenotonsillectomy. Complete follow-up data were available in 71 of 117 patients (61%).

Interventions

Parents completed the PSQ and CPRS-RS before surgery and 6 months after surgery.

Main Outcome Measures

Changes in age- and sex-adjusted T scores for all 4 CPRS-RS behavior categories (oppositional behavior, cognitive problems or inattention, hyperactivity, and Conners' attention-deficit/hyperactivity disorder [ADHD] index) were determined for each subject before and after surgery. Changes in PSQ scores from a select 22-item sleep-related breathing disorder subscale were also determined.

Results

Preoperatively, the mean (SD) T scores on the CPRS-RS for oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index were 59.4 (13.7), 59.5 (13.6), 62.0 (14.4), and 59.9 (13.4), respectively. A T score of 60.0 in any category placed a child in the at-risk group. Postoperatively, T scores for each category were 51.0 (9.6), 51.2 (8.8), 52.4 (10.52), and 50.6 (7.8), respectively. All changes were statistically significant (P < .001) and clinically significant by approximating a change of 1 SD from the baseline score. For the PSQ, the preoperative and postoperative mean (SD) scores were 0.6 (0.1) and 0.1 (0.1), respectively, on a scale of 0 to 1, with scores higher than 0.33 suggesting obstructive sleep apnea. Correlations between sleep and behavior scores were statistically significant before surgery (P = .004 for ADHD index and cognitive problems, P = .008 for oppositional behavior) and after surgery (P = .049 for cognitive problems,
P = .03 for oppositional behavior). Higher baseline T scores for the CPRS-RS were associated with larger changes in T scores for the CPRS-RS in all 4 domains (oppositional behavior, cognitive problems or inattention, hyperactivity, and ADHD index).

Conclusions

Children diagnosed as having SDB experience improvement in both sleep and behavior after adenotonsillectomy. The PSQ and CPRS-RS may be useful adjuncts for screening and following children who undergo adenotonsillectomy for SDB.

In children, the term sleep-disordered breathing (SDB) may be used more frequently than obstructive sleep apnea syndrome
(OSAS) because the former term recognizes that SDB is a spectrum of sleep-related breathing disorders (SRBDs) that includes primary snoring, upper airway resistance syndrome, obstructive hypoventilation, and OSAS (the most severe aspect of the spectrum). Although the prevalence of OSAS has been reported to range from 0.7% to 3%, the prevalence of snoring and clinical suspicion of SDB in children may approach 11%.
The impact of SDB on childhood development and behavior—specifically, hyperactivity and inattention—has been well published.

Using both polysomnography (PSG) and parental surveys, one study

showed that even though SDB is not more likely to occur among children with marked symptoms of attention-deficit/hyperactivity disorder (ADHD), it is highly prevalent among children with mild hyperactive behavior. At least 2 studies
have found that SDB is substantially more likely to be found among children with ADHD, unselected for sleep complaints, than among controls. Habitual snoring and SDB have been associated with ADHD, and it has been suggested that treatment of SDB may eliminate ADHD in a subset of children if their habitual snoring and SDB were alleviated.
Unlike OSAS, which is defined in part by a specific apnea-hypopnea index (AHI) based on PSG, SDB may be diagnosed clinically and may not consistently meet PSG criteria for an obstructive sleep breathing disorder.

In addition to hyperactivity, children with snoring and SDB have been shown to have neurocognitive impairment and poor school performance.

In one study, children without clinically significant hypoxia, as measured by pulse oximetry, but with habitual snoring have been shown to have poorer academic performance than those who do not snore. Sleep-disordered breathing is also associated with enuresis, learning disabilities, daytime sleepiness, and somatic complaints such as headaches.
Behavioral and emotional difficulties have been found in children with SDB before intervention, and improvements have been reported after adenotonsillectomy.

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Is obstructive sleep apnea associated with ADHD?

Youssef NA, Ege M, Angly SS, Strauss JL, Marx CE. Is obstructive sleep apnea associated with ADHD?.
Ann Clin Psychiatry. 2011;23(3):213-224.

Abstract

Background:

It has been suggested that obstructive sleep apnea (OSA) may result in symptoms similar to those experienced in attention-deficit/hyperactivity disorder (ADHD). Because this may have important public health implications, we reviewed the literature regarding this association, with a focus on interventional studies examining the effect of OSA treatment on change in ADHD symptoms.

Methods:

We performed a systematic literature search of PubMed, along with other major databases, for interventional studies published between January 1966 and June 2010 that examined the effect of OSA treatment on ADHD, which resulted in 6 studies. The literature on the prevalence of ADHD symptoms in OSA and vice versa was also reviewed.

Results:

Attentional deficits have been reported in up to 95% of OSA patients. In full syndromal ADHD, a high incidence (20% to 30%) of OSA has been shown. All 6 interventional studies reported improvements in behavior, inattention, and overall ADHD after treatment of OSA.

Conclusions:

OSA may contribute to ADHD symptomatology in a subset of patients diagnosed with ADHD (DSM-IV criteria). Treatment of OSA appears to have favorable effects on ADHD symptoms. Controlled trials and epidemiologic investigations will be required to better understand these relationships, as well as their diagnostic and prognostic implications.

Obstructive sleep apnea in children: implications for the developing central nervous system

Gozal D. Obstructive sleep apnea in children: implications for the developing central nervous system. Semin Pediatr Neurol. 2008 Jun;15(2):100-6. doi: 10.1016/j.spen.2008.03.006. PMID: 18555196; PMCID: PMC2490595.

Abstract

Recent increases in our awareness to the high prevalence of sleep disorders in general, and of sleep-disordered breathing among children, in particular, has led to concentrated efforts aiming to understand the pathophysiological mechanisms, clinical manifestations and potential consequences of such conditions. In this review, I will briefly elaborate on some of the pathogenetic elements leading to the occurrence of obstructive sleep apnea (OSA) in children, focus on the psycho-behavioral consequences of pediatric OSA, and review the evidence on the potential mechanisms underlying the close association between CNS morbidity and the episodic hypoxia and sleep fragmentation that characterize OSA.

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Lower Health Related Quality of Life and Psychosocial Difficulties in Children with Monosymptomatic Nocturnal Enuresis—Is Snoring a Marker of Severity?

Wolfe-Christensen C, Kovacevic LG, Mirkovic J, Lakshmanan Y. Lower health related quality of life and psychosocial difficulties in children with monosymptomatic nocturnal enuresis—Is snoring a marker of severity? J Urol. 2013;190(4 Suppl):1501-1504. doi:10.1016/j.juro.2013.01.060

Purpose

Sleep disordered breathing in children is linked to numerous negative psychosocial consequences, including lower health related quality of life, increased behavioral problems and impaired neuropsychological functioning. We examined whether snoring, which is the least severe form of sleep disordered breathing, or health related
quality of life could account for the increased rate of psychosocial difficulty in children with monosymptomatic nocturnal enuresis.

Materials and Methods

Patients diagnosed with monosymptomatic nocturnal enuresis seen at an outpatient pediatric urology clinic completed measures of health related
quality of life (Obstructive Sleep Apnea Syndrome–18-Item Questionnaire), sleep disordered breathing
(Pediatric Sleep Questionnaire) and psychosocial difficulty (Pediatric Symptom Checklist). Patients were categorized into 2 groups (snoring vs no snoring) based on the
Pediatric Symptom Checklist snoring subscale score.

Results

Included in the study were 62 males and 45 females with a mean ± SD age of 9.09 ± 2.58 years and a mean body mass index of 21.00 ± 6.93 kg/m2
(range 13 to 49). The sample was evenly split between 56 snorers (52.3%) and 51 non-snorers (47.7%). Compared to children with monosymptomatic nocturnal enuresis who did not snore, MANCOVA results revealed that patients with monosymptomatic nocturnal enuresis who snored had significantly more externalizing problems
and total psychosocial problems, in addition to significantly more impairment in all areas of health related of life.

Conclusions

Snoring in children with monosymptomatic nocturnal enuresis puts them at increased risk for behavioral and psychosocial problems, in addition to impaired health related quality of life. These findings support the need for future studies of the neurological links between sleep disordered breathing and monosymptomatic
nocturnal enuresis.

Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis

Umlauf M, Chasens E. Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev. 2003;7(5):403-411. doi:10.1053/smrv.2002.0273

Abstract

Although nocturnal voiding is frequently attributed to urologic disorders, nocturia and enuresis are also important symptoms of sleep-disordered breathing. However, polyuria can be elicited by obstructive sleep apnea as well as bedrest, microgravity and other experimental conditions where the blood volume is shifted centrally to the upper body. The nocturnal polyuria of sleep apnea is an evoked response to conditions of negative intrathoracic pressure due to inspiratory effort posed against a closed airway. The mechanism for this natriuretic response is the release of atrial natriuretic peptide due to cardiac distension caused by the negative pressure environment. This cardiac hormone increases sodium and water excretion and also inhibits other hormone systems that regulate fluid volume, vasopressin and the rennin-angiotensin-aldosterone complex. Treatment of sleep apnea and airway compromise has been shown to reverse nocturnal polyuria and thereby reduce or eliminate nocturia and enuresis. Thus, careful evaluation of nocturia and enuresis for evidence of nocturnal polyuria can increase the diagnostic certainty of referring primary care providers and sleep specialists. In addition, the resolution of these bothersome symptoms after treatment can contribute to patient satisfaction as well as reinforce treatment compliance.

A Significant Increase in Breathing Amplitude Precedes Sleep Bruxism

Khoury S, Rouleau GA, Rompré PH, Mayer P, Montplaisir JY, Lavigne GJ. A significant increase in breathing amplitude precedes sleep bruxism. Chest. 2008;134(2):332-337. doi:10.1378/chest.08-0115

Abstract

Sleep bruxism (SB) is a stereotyped movement disorder that is characterized by rhythmic masticatory muscle activity (RMMA) and tooth grinding. Evidence has suggested that SB is associated with sleep arousals and that most RMMA episodes are preceded by physiologic changes occurring in sequence, namely, a rise in autonomic sympathetic-cardiac activity followed by a rise in the frequency of EEG and suprahyoid muscle activity. In the present study, we hypothesize that an increase in respiration also characterizes the onset of SB within the arousal sequence.

Methods

Polygraphic sleep recordings of 20 SB subjects without any sleep-related breathing disorders were analyzed for changes in respiration (ie, root mean square, area under the curve, peak, peak-to-peak, and length) extracted from a
nasal cannula
signal. Variables were analyzed and compared using analysis of variance and correlation tests.

Results

Measurements of respiration showed significant changes over time. Four seconds before RMMA muscle activity, the amplitude of respiration is already increased (8 to 23%); the rise is higher at the onset of the suprahyoid activity (60 to 82% 1 s before RMMA); the rise is maximal during RMMA (108 to 206%) followed by a rapid return to levels preceding RMMA. A positive and significant correlation was found between the frequencies of RMMA episodes and the amplitude of breath (R2
= 0.26; p = 0.02). The amplitude of respiratory changes was 11 times higher when arousal was associated with RMMA in comparison to arousal alone.

Conclusions

To our knowledge, this is the first report showing that RMMA-SB muscle activity is associated with a rise in respiration within arousal.

The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients

Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope. 2010 Oct;120(10):2089-93. doi: 10.1002/lary.20991. PMID: 20824738.

Abstract

Objectives/hypothesis:
To determine the effect of mouth breathing during childhood on craniofacial and dentofacial development compared to nasal breathing in malocclusion patients treated in the orthodontic clinic.

Study design:
Retrospective study in a tertiary medical center.

Methods:
Clinical variables and cephalometric parameters of 116 pediatric patients who had undergone orthodontic treatment were reviewed. The study group included 55 pediatric patients who suffered from symptoms and signs of nasal obstruction, and the control group included 61 patients who were normal nasal breathers.

Results:
Mouth breathers demonstrated considerable backward and downward rotation of the mandible, increased overjet, increase in the mandible plane angle, a higher palatal plane, and narrowing of both upper and lower arches at the level of canines and first molars compared to the nasal breathers group. The prevalence of a posterior cross bite was significantly more frequent in the mouth breathers group (49%) than nose breathers (26%), (P = .006). Abnormal lip-to-tongue anterior oral seal was significantly more frequent in the mouth breathers group (56%) than in the nose breathers group (30%) (P = .05).

Conclusions:
Naso-respiratory obstruction with mouth breathing during critical growth periods in children has a higher tendency for clockwise rotation of the growing mandible, with a disproportionate increase in anterior lower vertical face height and decreased posterior facial height.

Mouth breathing children have cephalometric patterns similar to those of adult patients with obstructive sleep apnea syndrome.

Juliano ML, Machado MA, Carvalho LB, Prado LB, do Prado GF. Mouth breathing children have cephalometric patterns similar to those of adult patients with obstructive sleep apnea syndrome.
Arq Neuropsiquiatr. 2009;67(3B):860-865. doi:10.1590/s0004-282x2009000500015

Abstract

Objective:

To determine whether mouth breathing children present the same cephalometric patterns as patients with obstructive sleep apnea syndrome (OSAS).

Method:

Cephalometric variables were traced and measured on vertical lateral cephalometric radiographs. The cephalometric measurements of 52 mouth and 90 nose breathing children were compared with apneic patients. The children had not undergone adenoidectomy or tonsillectomy and had not had or were not receiving orthodontic or orthopedic treatment.

Results:

Mouth breathing children showed same cephalometric pattern observed in patients with OSAS: a tendency to have a retruded mandible (p=0.05), along with greater inclination of the mandibular and occlusal planes (p<0.01) and a tendency to have greater inclination of the upper incisors (p=0.08). The nasopharyngeal and posterior airway spaces were greatly reduced in mouth breathing children, as observed in patients with apnea (p<0.01).

Conclusion:

Mouth breathing children present abnormal cephalometric parameters and their craniofacial morphology resembles that of patients with OSAS.

Maxillomandibular Advancement in Obstructive Sleep Apnea Syndrome Patients: a Restrospective Study on the Sagittal Cephalometric Variables

Ronchi P, Cinquini V, Ambrosoli A, Caprioglio A. Maxillomandibular advancement in obstructive sleep apnea syndrome patients: a retrospective study on the sagittal cephalometric variables. J Oral Maxillofac Res. 2013;4:e5. doi:10.5037/jomr.2013.4205

Objectives: The present retrospective study analyzes sagittal cephalometric changes in patients affected by obstructive sleep apnea syndrome submitted to maxillomandubular advancement. Material and Methods: 15 adult sleep apnea syndrome (OSAS) patients diagnosed by polysomnography (PSG) and treated with maxillomandubular advancement (MMA) were included in this study. Pre- (T1) and postsurgical (T2) PSG studies assessing the apnea/hypopnea index (AHI) and the lowest oxygen saturation (LSAT) level were compared. Lateral cephalometric radiographs at T1 and T2 measuring sagittal cephalometric variables (SNA, SNB, and ANB) were analyzed, as were the amount of maxillary and mandibular advancement (Co-A and Co-Pog), the distance from the mandibular plane to the most anterior point of the hyoid bone (Mp-H), and the posterior airway space (PAS).Results: Postoperatively, the overall mean AHI dropped from 58.7 ± 16 to 8.1 ± 7.8 events per hour (P < 0.001). The mean preoperative LSAT increased from 71% preoperatively to 90% after surgery (P < 0.001). All the patients in our study were successfully treated (AHI < 20 or reduced by 50%). Cephalometric analysis performed after surgery showed a statistically signicant correlation between the mean SNA variation and the decrease in the AHI (P = 0.01). The overall mean SNA increase was 6°.Conclusions: Our findings suggest that the improvement observed in the respiratory symptoms, namely the apnea/hypopnea episodes, is correlated with the SNA increase after surgery. This finding may help maxillofacial surgeons to establish selective criteria for the surgical approach to sleep apnea syndrome patients

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Is There a Link Between Obstructive Sleep Apnea Syndrome and Fibromyalgia Syndrome?

Köseoğlu Hİ, İnanır A, Kanbay A, et al. Is There a Link Between Obstructive Sleep Apnea Syndrome and Fibromyalgia Syndrome?.
Turk Thorac J. 2017;18(2):40-46. doi:10.5152/TurkThoracJ.2017.16036

OBJECTIVES

Fibromyalgia syndrome (FMS) is characterized by complaints of chronic musculoskeletal pain, fatigue, and difficulty in falling asleep. Obstructive sleep apnea syndrome (OSAS) is associated with symptoms, such as morning fatigue and unrefreshing sleep. We aimed to investigate the presence of OSAS and objectively demonstrate changes in sleep pattern in patients with FMS.

MATERIAL AND METHODS

Polysomnographic investigations were performed on 24 patients with FMS. Patients were divided into two groups: patients with and without OSAS (Group 1 and Group 2, respectively). A total of 40 patients without FMS who presented to the sleep disorders polyclinic with an initial diagnosis of OSAS were included in Group 3. Based on their apnea hypopnea index (AHI), OSAS in the patients were categorized as mild (AHI, 5–15), moderate (30), or severe (>30).

RESULTS

OSAS was detected in 50% of patients with FMS. The most prominent clinical findings were morning fatigue and sleep disorder, which were similar in three groups. In polysomnography (PSG) evaluation, patients with FMS had mild (33%), moderate (25%), and severe (42%) OSAS. In correlation analyses, negative correlations were observed between fibromyalgia impact questionnaire (FIQ) and mean oxygen saturation, visual analogue scale (VAS), and minimum oxygen saturation, whereas a positive correlation was found between FIQ and desaturation times in patients with FMS.

CONCLUSION

Detection of OSAS in 50% of the patients with FMS, and similar rates of complaints of sleep disorder and morning fatigue of OSAS and FMS cases are important results. Detection of correlation between the severity of hypoxemia and FIQ and VAS scores are significant because it signifies the contribution of increased tissue hypoxemia to the deterioration of clinical status. Diagnosis and treatment of OSAS associated with FMS are important because of their favorable contributions to the improvement of the clinical picture of FMS.

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Coexistence of obstructive sleep apnea syndrome and fibromyalgia

Altıntop Geçkil A, Aydoğan Baykara R. Coexistence of obstructive sleep apnea syndrome and fibromyalgia. Obtrüktif uyku apne sendromu ile fibromiyalji birlikteliği.
Tuberk Toraks. 2022;70(1):37-43. doi:10.5578/tt.20229905

Abstract

Introduction:

Fibromyalgia is characterized by pain all over the body, whose diagnosis and treatment are not fully understood. Obstructive sleep apnea syndrome (OSAS) is a disease that causes apnea, hypopnea and oxygen desaturation due to collapse in the upper respiratory tract and is characterized by excessive daytime sleepiness, fatigue and lack of attention. Symptoms and signs of OSAS and fibromyalgia are similar. In our study, we aimed to compare the association of fibromyalgia in female OSAS patients in terms of polysomnography and laboratory parameters.

Materials and methods:

We aimed to examine the association of fibromyalgia in patients with female OSAS. A total of 190 female OSAS patients were included in the study. The patients were divided into two groups according to the presence of fibromyalgia: 88 (46.3%) patients in the fibromyalgia group and 102 (53.7%) patients in the control group. Statistical Package for the Social Sciences (SPSS) program was used for the evaluation of demographic data, polysomnography parameters and laboratory tests of the patients, and values with p<0.05 were considered statistically significant.

Result:

Mean age of the patients was 52.1 ± 11.9 years and mean body mass index (BMI) was 35.1 ± 7.2. There was no difference between age and BMI (p= 0.971, p= 0.716, respectively). Periodic leg movements (PLMS) were higher in the fibromyalgia group (p= 0.02). The desaturation index (CT90) was found to be high in the fibromyalgia group (p= 0.043). The minimum SaO2 value was found to be low in the fibromyalgia group (p= 0.022). Sleep latency was found to be higher in the fibromyalgia group (p= 0.031). Hemoglobin and hematocrit values were found to be statistically significantly higher in the fibromyalgia group (p= 0.020, p= 0.027, respectively). Triglyceride level was found to be high in the fibromyalgia group (p= 0.043).

Conclusions:

We recommend clinical evaluation of female patients with fibromyalgia and we suggest polysomnography, especially in patients with excessive daytime sleepiness. Early diagnosis and treatment of concomitant OSAS will contribute to quality of fibromyalgia patients' life.

Comparison of sleep structure in patients with fibromyalgia and healthy controls

Çetin, B., Sünbül, E.A., Toktaş, H. et al. Comparison of sleep structure in patients with fibromyalgia and healthy controls.

Sleep Breath 24, 1591–1598 (2020). https://doi.org/10.1007/s11325-020-02036-x

Abstract

Background

Sleep disturbances such as nonrestorative sleep and nighttime awakenings play a crucial role in fibromyalgia (FMS). Pain and sleep disturbances show a bidirectional relationship which affect outcomes in FMS. This study aims to compare sleep structures between patients with fibromyalgia and healthy controls.

Methods

We evaluated subjective and objective sleep structures of 33 patients with fibromyalgia and 34 healthy controls using the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and polysomnography. Student’s

T test, chi-square, discriminant analysis, the Kruskal-Wallis, and Mann-Whitney

U test were used for statistical analysis.

Results

Patients with FMS reported poorer sleep quality than controls ( p= 0.003). Polysomnography data showed patients with FMS exhibited a greater number of awakenings

p= 0.01), more arousals ( p = 0.00), higher arousal index ( p = 0.00), greater apnea hypopnea index ( p = 0.03), and less N1 sleep (p= 0.02) than healthy controls. The discriminant analysis revealed that number of arousals, arousal index, and N1 sleep were able to distinguish patients with FMS from healthy controls with 78.5% accuracy. Twelve of the 33 patients with FMS were diagnosed with obstructive sleep apnea syndrome (OSAS). When we excluded patients with OSAS, a statistically significant difference was maintained.

Conclusions

Our findings may explain the deterioration of subjective sleep, symptoms as unrefreshing sleep, fatigue, and pain in patients with FMS. Despite similar clinical manifestations, patients with FMS should be evaluated for OSAS due to treatment differences. The role of sleep alterations in the clinical manifestation and severity of FMS suggest that effective treatments to improve sleep quality may lead to more effective management of FMS.

The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders

Adopted by ADA’s 2017 House of Delegates

Sleep related breathing disorders (SRBD) are disorders characterized by disruptions in normal breathing patterns. SRBDs are potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms. Common SRBDs include snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). OSA has been associated with metabolic, cardiovascular, respiratory, dental and other diseases. In children, undiagnosed and/or untreated OSA can be associated with cardiovascular problems, impaired growth as well as learning and behavioral problems. Dentists can and do play an essential role in the multidisciplinary care of patients with certain sleep related breathing disorders and are well positioned to identify patients at greater risk of SRBD. SRBD can be caused by a number of multifactorial medical issues and are therefore best treated through a collaborative model. Working in conjunction with our colleagues in medicine, dentists have various methods of mitigating these disorders. In children, the dentist’s recognition of suboptimal early craniofacial growth and development or other risk factors may lead to medical referral or orthodontic/orthopedic intervention to treat and/or prevent SRBD. Various surgical modalities exist to treat SRBD. Oral appliances, specifically custom-made, titratable devices can improve SRBD in adult patients compared to no therapy or placebo devices. Oral appliance therapy (OAT) can improve OSA in adult patients, especially those who are intolerant of continuous positive airway pressure (CPAP). Dentists are the only health care provider with the knowledge and expertise to provide OAT. The dentist’s role in the treatment of SRBD includes the following:

Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. If risk for SRBD is determined, these patients should be referred, as needed, to the appropriate physicians for proper diagnosis.

In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.

Oral appliance therapy is an appropriate treatment for mild and moderate sleep apnea, and for severe sleep apnea when a CPAP is not tolerated by the patient.

When oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with obstructive sleep apnea, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance. If deemed appropriate, a dentist should fabricate an oral appliance.

Dentists should obtain appropriate patient consent for treatment that reviews the proposed treatment plan, all available options and any potential side effects of using OAT and expected appliance longevity.

Dentists treating SRBD with OAT should be capable of recognizing and managing the potential side effects through treatment or proper referral.

Dentists who provide OAT to patients should monitor and adjust the Oral Appliance (OA) for treatment efficacy as needed, or at least annually. As titration of OAs has been shown to affect the final treatment outcome and overall OA success, the use of unattended cardiorespiratory (Type 3) or (Type 4) portable monitors may be used by the dentist to help define the optimal target position of the mandible. A dentist trained in the use of these portable monitoring devices may assess the objective interim results for the purposes of OA titration.

Surgical procedures may be considered as a secondary treatment for OSA when CPAP or OAT is inadequate or not tolerated. In selected cases, such as patients with concomitant dentofacial deformities, surgical intervention may be considered as a primary treatment.

Dentists treating SRBD should continually update their knowledge and training of dental sleep medicine with related continuing education.

Dentists should maintain regular communications with the patient’s referring physician and other healthcare providers to the patient’s treatment progress and any recommended follow-up treatment.

Follow-up sleep testing by a physician should be conducted to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.

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