7 Ways to Speed Up Aging

If you don't know Steven Park yet, now's a good time to get familiar with him.  An ENT who focuses on sleep and breathing issues, he authored "Sleep Interrupted" here, runs a biweekly webinar on sleep issues, teaches at Montefiore, and wrote this clever article last year that should be read by all.

7 Ways to Speed Up Aging | Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring

On Early Treatment and Sleep Apnea

Here is a Letter to the Editor of the AJODO (orthodontic's premier journal) about two articles on sleep apnea. One article extolled the virtues of using appliances to treat sleep apnea and the other jaw surgery.  While both have their place, both miss the point, as you shall see...

Point/CounterCounterpoint: 

Treating obstructive sleep apnea:  The case for early treatment.

by Dr. Barry Raphael, Clifton, NJ

I was thrilled to see sleep apnea being discussed in the October 2012 (142:4) issue.  This is a timely topic that needs to be seriously considered by all orthodontists.  Many of our patients are victims of sleep disordered breathing.

We know that the underdeveloped maxilla  is a primary risk factor for obstructive issues (Dempsey, et.al., 2002), and that a majority of malocclusions, including Class II’s, have an underdeveloped maxilla (McNamara, 1981).

Connect the dots backward from the adult sleep apneic to the growing child to see the connection:  if a child’s face grows poorly from the beginning, s/he will be more susceptible to airway restriction as an adult.

While Drs. Jacobson and Schendel drew appropriate recognition to this issue by recognizing the importance of maxillomandibular advancement to relieve the airway in children, they quickly jumped to discussing surgery in craniofacial anomalies completely skipping over the vast majority of children with similar but less severe problems.  They were completely on target, however, in stipulating that “the orthodontist can play a major role” with interceptive therapy at early ages.

I would like to propose two issues that bear immediate discussion in our profession :

1. We need  the diagnosis of Bimaxillary Retrusion in our thinking.  Most Class II malocclusions are maxillary retrusive.  And just because the dentition is Class I doesn’t mean it is properly placed in the face.
2. There are approaches to orthopedically correcting bimaxillary retrusion in the growing child, but they must be started EARLY.  Waiting for the facial skeleton to be 90% grown before we commence therapy, as the ongoing discussion on early treatment is leading many of us to, is much too late.  By then, the maxilla has collapsed transversely, vertically and sagitally and the mandible has compensated for its partner’s limitation.  Dental compensation doesn’t help (and may hinder)...only orthognathics does.

The American Academy of Pediatrics (Marcus, et.al. 2012) issued guidelines regarding OSA in children.  Though T&A is now (finally) the first line of defense in children with OSA, at least one of the panel members (Sheldon, 2012) has stated publicly that dentofacial orthopedics (in his case, Biobloc Orthotropics) will likely be the future of pediatric sleep medicine.

I urge all of us to take a second look at these issues in light of the coming epidemic of sleep disordered breathing.  The children require it.  And we need to be the ones treating it. 

References:

Dempsey, Jerome, et.al, Anatomic Determinants of SleepDisordered Breathing.  CHEST 2002;122(3), 840-851.

Marcus, Carol, et.al, Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome -Clinical Guidelines. Published at http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672 

McNamara, James,  Components of Class II Malocclusion in Children 8-10 Years of Age, Angle Orthodontist, 1981;51(3):177-202.

Sheldon, Stephen, Children and Airway: Issues and Interventions,  at NYU, October 6, 2012