The buccal frenum: Trends in diagnosis and indications for treatment of buccal-ties among 466 healthcare professionals.

BACKGROUND: The buccal frenum is connective tissue that adheres the mucosa of the cheek to the alveolar process. When restricted, this condition is commonly known as a buccal- or cheek-tie. Restrictive buccal frena are often treated during tongue- and lip-tie procedures, yet widely accepted classification, diagnostic and treatment guidelines are lacking. OBJECTIVE: Provide a scoping review on the evaluation and management of buccal-ties, including diagnosis, classification, symptoms and treatment, by surveying healthcare providers with experience evaluating and managing oral restrictions. METHODS: Literature review and IRB-approved survey to assess practice patterns among healthcare providers identified from online directories of tongue-tie release providers and associated allied health professionals. RESULTS: A multidisciplinary group of 466 providers responded. About 87% indicated that they assess buccal restrictions. Evaluation methods included finger sweep (89.1%), visual inspection (76.4%), tissue blanching (66.5%) and functional assessment (53.4%). Around 94% of providers reported that objective and subjective findings are both needed for diagnosis and that an estimated 5%-10% of infants may be affected. About 70% of providers release buccal-ties (if needed) simultaneously with tongue-ties, and 76.8% recommend post-operative stretches as necessary for optimal healing. Respondents indicated a need for further research, evidence-based assessments, a classification system and treatment protocols. CONCLUSION: Evaluating a buccal frenum to diagnose a symptomatic buccal-tie relies upon visual inspection, palpation and assessment of oral function. Survey data and clinical experience are summarized to review classification systems, diagnostic/evaluation criteria and treatment recommendations as a foundational cornerstone for future works to build upon.

Does Head and Neck Posture Affect Cone-Beam Computed Tomography Assessment of the Upper Airway?

PURPOSE: Radiographic analysis is often used as a screening tool to assess for risk of sleep-related breathing disorders. This study aimed to address 2 questions: (1) Does head posture significantly affect the minimum cross-sectional area (MCA)? and (2) Is the NBC3 (nasion-basion-C3) angle a reliable measurement to control for alteration of head position in cone-beam computed tomography (CBCT) scans? METHODS: Study design: prospective cohort study. SETTING: Private practices affiliated with a research institution. PARTICIPANTS: convenience sample of adult volunteers. VARIABLES: CBCT scans were taken in 2 conditions: baseline (natural head position, NHP) and 1 of 5 experimental conditions (head tilted up, head tilted down, sitting vs standing, use of chin-rest, and swallow variation). For the primary aim of our study, the primary predictor variable was head posture and the main outcome variable was percentage change in MCA. For the secondary aim, the primary predictor variable was head posture and the main outcome variable was degree change in NBC3 angle. RESULTS: Ninety subjects were included (age 40.7 ± 13.7 years, 70% female). Mean NBC3 at baseline was 112.4 ± 8.3°. Head tilted down significantly decreased (-41.4 ± 18.5 mm2, P = .03∗) and head tilted up significantly increased MCA (+147.4 ± 43.3 mm2, P = .0018∗). Head tilted down significantly reduced the NBC3 angle measurement (-10.5 ± 6.8°, P = .006) and head tilted up significantly increased the NBC3 angle measurement (+14.4 ± 5.8°, P = .0004). A quadratic regression model was fitted with moderately strong correlation (R2 = 0.54) showing an exponential effect of small changes in the NBC3 angle on MCA, P < .0001. The model predicts that increasing NBC3 by +5 and + 10° resulted in MCA changes of +25% and +88%, whereas a decrease in NBC3 by -5 and -10° results in MCA changes of -21% and -23%, respectively. CONCLUSION: Alterations in head posture significantly affect the MCA of the upper airway on CBCT. The NBC3 angle can be used to reliably assess changes in cranio-cervical extension and validate comparisons of MCA between CBCT scans for the same patient. A standardized protocol for CBCT acquisition is proposed.

Assessment of posterior tongue mobility using lingual-palatal suction: Progress towards a functional definition of ankyloglossia.

BACKGROUND: A functional definition of ankyloglossia has been based on assessment of tongue mobility using the tongue range of motion ratio (TRMR) with the tongue tip extended towards the incisive papilla (TIP). Whereas this measurement has been helpful in assessing for variations in the mobility of the anterior one-third of the tongue (tongue tip and apex), it may be insufficient to adequately assess the mobility of the posterior two-thirds body of the tongue. A commonly used modification is to assess TRMR while the tongue is held in suction against the roof of the mouth in lingual-palatal suction (LPS). OBJECTIVE: This study aims to explore the utility and normative values of TRMR-LPS as an adjunct to functional assessment of tongue mobility using TRMR-TIP. STUDY DESIGN: Cross-sectional cohort study of 611 subjects (ages: 3-83 years) from the general population. METHODS: Measurements of tongue mobility using TRMR were performed with TIP and LPS functional movements. Objective TRMR measurements were compared with subjective self-assessment of resting tongue position, ease or difficulty elevating the tongue tip to the palate, and ease or difficulty elevating the tongue body to the palate. RESULTS: There was a statistically significant association between the objective measures of TRMR-TIP and TRMR-LPS and subjective reports of tongue mobility. LPS measurements were much more highly correlated with differences in elevating the posterior body of the tongue as compared to TIP measurements (R2 0.31 vs 0.05, P < .0001). CONCLUSIONS: This study validates the TRMR-LPS as a useful functional metric for assessment of posterior tongue mobility.

Optimizing mandibular sagittal split of large maxillomandibular advancements for obstructive sleep apnea: patient and surgical factors.

OBJECTIVES: Maxillomandibular advancement (MMA) confers consistent and high rates of surgical success for obstructive sleep apnea (OSA). In the era of value-based medicine, identifying factors that affect the stability of rigid fixation and allow rapid return to function are important targets for improvement. The aim of this study was to identify patient and surgical factors associated with mandibular sagittal split outcomes associated with optimal postoperatively skeletal stability. STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Forty-six subjects (43 males and 3 females) with postoperative CT scans including three-dimensional reconstruction from which mandibular split patterns could be analyzed were enrolled. Patient factors (age and polysomnographic measures) and surgical factors (extent of osteotomy prior to controlled fracture) were assessed. Outcome measures include (1) bone thickness for rigid fixation and (2) area of passive bony overlap after advancement. RESULTS: Age and severity of disease did not contribute significantly to optimal mandibular split patterns. For optimal area for passive bony overlap and thickness of buccal and lingual plates for rigid fixation, the most important factors are related to surgical technique. CONCLUSIONS: Anterior osteotomy just to the midline of inferior border and horizontal osteotomy to the mandibular foramen are associated with split patterns that result in optimal rigid fixation and passive bony overlap for OSA patients undergoing MMA. CLINICAL RELEVANCE: Optimal surgical technique has the most significant influence in allowing rapid return to function after MMA in patients with OSA.

Neuromuscular function of the soft palate and uvula in snoring and obstructive sleep apnea: A systematic review.

OBJECTIVE: A collapsible upper airway is a common cause of obstructive sleep apnea. The exact pathophysiology leading to a more collapsible airway is not well understood. A progressive neuropathy of the soft palate and pharyngeal dilators may be associated with the progression of snoring to OSA. The purpose of this study is to systematically review the international literature investigating the neurophysiologic changes in the soft palate and uvula that contribute to progression from snoring to OSA. METHODS: PubMed/MEDLINE and 4 other databases were systematically searched through July 4, 2017. Eligibility: (1) Patients: controls, snoring or OSA patients (2) Intervention: neuromuscular evaluation of the palate and/or uvula (3) Comparison: differences between controls, snoring and OSA patients (4) Outcomes: neuromuscular outcomes (5) Study design: Peer reviewed publications of any design. RESULTS: 845 studies were screened, 76 were downloaded in full text form and thirty-one studies met criteria. Histological studies of the soft palate demonstrated diffuse inflammatory changes, muscular changes consistent with neuropathy, and neural aberrancies. Sensory testing studies provided heterogeneous outcomes though the majority favored neuronal dysfunction. Studies have consistently demonstrated that increasing severity of snoring and sleep apnea is associated with worsening sensory nerve function of the palate in association with atrophic histological changes to the nerves and muscle fibers of the soft palate and uvula. CONCLUSIONS: Recent evidence highlighted in this systematic review implicates the role of neurogenic pathology underlying the loss of soft palate and/or uvular tone in the progression of snoring to sleep apnea.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis.

PURPOSE: Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy. METHODS: PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs. RESULTS: A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time. CONCLUSIONS: This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects.

PURPOSE: Alterations of the lingual frenulum may contribute to oromyofacial dysfunction, speech and swallowing impediments, underdevelopment of the maxillofacial skeleton, and even predispose to sleep breathing disorder. This study aims to assess the utility of existing instruments for evaluation of restricted tongue mobility, describe normal and abnormal ranges of tongue mobility, and provide evidence in support of a reliable and efficient measure of tongue mobility. METHODS: A prospective cohort study of 1052 consecutive patients was evaluated during a 3-month period. Age, gender, ethnicity, height, weight, BMI, maximal interincisal mouth opening (MIO), mouth opening with tongue tip to maxillary incisive papillae at roof of mouth (MOTTIP), Kotlow's free-tongue measurement, and presence of severe tongue-tie were recorded. Secondary outcome measures include tongue range of motion deficit (TRMD, difference between MIO and MOTTIP) and tongue range of motion ratio (TRMR, ratio of MOTTIP to MIO). RESULTS: Results indicate that MIO is dependent on age and height; MOTTIP and TRMD are dependent on MIO; Kotlow's free-tongue measurement is an independent measure of free-tongue length and tongue mobility. TRMR is the only independent measurement of tongue mobility that is directly associated with restrictions in tongue function. CONCLUSIONS: We propose the use of tongue range of motion ratio as an initial screening tool to assess for restrictions in tongue mobility. "Functional" ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50-80%, grade 3 < 50%, grade 4 < 25%.

Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review.

BACKGROUND: The purpose of the present study is to review the international literature, using a systematic review, for studies comparing propofol and dexmedetomidine for drug-induced sleep endoscopy (DISE) or sedation in which there is a description of the effect of the agents on the upper airway and associated variables (e.g., vital signs, sedation scores). METHODS: This is a systematic review through October 4, 2016. PubMed/MEDLINE and four additional databases were accessed for this study. RESULTS: Two hundred twenty studies were screened, 79 were downloaded, and 10 met criteria. The majority of the studies identified dexmedetomidine as the preferred pharmacologic agent for DISE due to an overall safer and more stable profile based upon hemodynamic stability. However, propofol provided greater airway obstruction with oxygen desaturations. With either agent, the degree of obstruction in the upper airway lacks some degree of validity as to whether the obstructions accurately represent natural sleep or are simply a drug-induced effect. CONCLUSION: Dexmedetomidine and propofol have their advantages and disadvantages during DISE. Generally, dexmedetomidine was preferred and seemed to provide a more stable profile based upon cardiopulmonary status. However, propofol has a quicker onset, has a shorter half-life, and can demonstrate larger degrees of obstruction, which might more accurately reflect what happens during REM sleep. Additional research is recommended.

Tongue surgeries for pediatric obstructive sleep apnea: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the international literature for studies reporting outcomes for obstructive sleep apnea (OSA) in children undergoing isolated tongue surgeries. METHODS: Two authors searched from inception through November 14, 2016 in four databases including PubMed/MEDLINE. RESULTS: 351 studies were screened. Eleven studies (116 children) met criteria. Most children were syndromic and had craniofacial disorders, co-morbidities, or other serious medical issues. Surgeries included base-of-tongue (BOT) reduction (n = 114), tongue suspension (n = 1), and hypoglossal nerve stimulation (n = 1). The pre- and post-BOT reduction surgeries decreased apnea-hypopnea index (AHI) from a mean (M) and standard deviation (SD) of 16.9 ± 12.2/h to 8.7 ± 10.6/h (48.5% reduction) in 114 patients. Random effects modeling (109 patients) demonstrated a standardized mean difference for AHI of -0.78 (large magnitude of effect) [95% CI -1.06, -0.51], p value <0.00001. For BOT surgery in 53 non-syndromic children, the AHI decreased 59.2% from 14.0 ± 11.4 to 5.7 ± 6.7/h, while in 55 syndromic children, the AHI decreased 40.0% from 20.5 ± 19.1 to 12.3 ± 18.2/h. BOT reduction improved lowest oxygen saturation from M ± SD of 84.7 ± 7.4-87.9 ± 6.5% in 113 patients. Hypoglossal nerve stimulation and tongue-base suspension are limited to case reports. CONCLUSIONS: Most children undergoing tongue surgeries in the literature were syndromic and had craniofacial disorders, co-morbidities, or other serious medical issues. Children with a body mass index <25 kg/m2 and non-syndromic children have had the most improvement in AHI. The specific type of surgery must be tailored to the patient. Patients with co-morbidities should undergo treatment in centers that are equipped to provide appropriate perioperative care.

MRI criteria for the diagnosis of pleomorphic adenoma: a validation study.

OBJECTIVES: To validate an MRI algorithm characteristic of pleomorphic adenoma (PA). STUDY DESIGN: Cross-sectional analysis. SETTING: Academic tertiary-care medical center. METHODS: A radiologic algorithm for the MRI diagnosis of PA was developed on the basis of five "high probability" criteria that all must be fulfilled for the MRI to qualify as a positive test result: bright T2-signal, sharp margins, heterogeneous nodular enhancement, lobulated contours, T2-dark rim. We then identified MRI images from our institutional database to test the diagnostic accuracy of the proposed algorithm. RESULTS: A total of 103 parotidectomy cases with adequate MRI studies were identified (pleomorphic adenoma n=41, mucoepidermoid carcinoma n=11, Warthin's tumor n=8, adenoid cystic carcinoma n=6, oncocytoma n=6, acinic cell carcinoma n=5, salivary duct carcinoma n=5, and other n=21). Eighteen of 21 cases that met all five "high probability" MRI criteria were consistent with PA on final histopathology; 3 were consistent with carcinoma. MRI had a specificity of 95.1% [95% confidence interval: 85.6-98.7%] and sensitivity of 43.9% [95% C.I.: 28.8-60.1%] for PA. The positive predictive value was 85.7% [95% C.I.: 70.4-100%] and the negative predictive value was 71.9% [95% C. I.: 62.0-81.9%]. The overall diagnostic accuracy was 74.8% [95% C.I.: 66.2-83.3%]. CONCLUSION: A "high probability" MRI is about 95% specific for pleomorphic adenoma. A subset of patients with MRI imaging that is highly suggestive of PA may reliably avoid further workup. The value of MRI in this setting is especially useful if preoperative fine needle aspiration is not readily available. A significant proportion of PAs, however, have indeterminate imaging features that overlap considerably with other benign and malignant lesions.

Oncologic validity of recipient vessel preservation in microvascular free-flap reconstruction.

OBJECTIVES: The use of free-flap reconstruction requires a more limited neck dissection to allow for microvascular anastomosis. This study seeks to determine the oncologic validity of cervical vessel preservation. MATERIALS AND METHODS: The current study is a prospective review of cervical vessel biopsies from patients undergoing resection of squamous cell carcinoma (SCCA) tumors of the head and neck with free tissue reconstruction. RESULTS: From June 2010 to March 2012, 227 recipient vessel biopsies were performed on 100 patients. Three of these patients had grossly abnormal vessels, with malignancy confirmed by frozen section analysis. One patient had a vessel positive for malignancy that was grossly normal but found to have SCCA on the final pathology. CONCLUSIONS: When the recipient vessel appears grossly suspicious, a frozen section biopsy and re-resection should be considered. Recipient vessel trimmings should routinely be sent for permanent pathology since in rare cases, they can be involved by tumor, affecting the margin status, prognosis, and indications for adjuvant therapy.

tDCS-induced analgesia and electrical fields in pain-related neural networks in chronic migraine.

OBJECTIVE: We investigated in a sham-controlled trial the analgesic effects of a 4-week treatment of transcranial direct current stimulation (tDCS) over the primary motor cortex in chronic migraine. In addition, using a high-resolution tDCS computational model, we analyzed the current flow (electric field) through brain regions associated with pain perception and modulation. METHODS: Thirteen patients with chronic migraine were randomized to receive 10 sessions of active or sham tDCS for 20 minutes with 2 mA over 4 weeks. Data were collected during baseline, treatment and follow-up. For the tDCS computational analysis, we adapted a high-resolution individualized model incorporating accurate segmentation of cortical and subcortical structures of interest. RESULTS: There was a significant interaction term (time vs group) for the main outcome (pain intensity) and for the length of migraine episodes (ANOVA, P < .05 for both analyses). Post-hoc analysis showed a significant improvement in the follow-up period for the active tDCS group only. Our computational modeling studies predicted electric current flow in multiple cortical and subcortical regions associated with migraine pathophysiology. Significant electric fields were generated, not only in targeted cortical regions but also in the insula, cingulate cortex, thalamus, and brainstem regions. CONCLUSIONS: Our findings give preliminary evidence that patients with chronic migraine have a positive, but delayed, response to anodal tDCS of the primary motor cortex. These effects may be related to electrical currents induced in pain-related cortical and subcortical regions.

Analysis of surgical margins in cases of mandibular osteoradionecrosis that progress despite extensive mandible resection and free tissue transfer.

INTRODUCTION: Approximately 1 of 4 patients with osteoradionecrosis (ORN) of the mandible develop ongoing disease despite extensive mandible resection to margins determined by the presence of bleeding bone at the time of surgery. OBJECTIVE: To determine whether pathologic examination of bony margins in assessing for the presence of necrotic edges is correlated with ongoing ORN. METHODS: Resected mandible specimens from 34 patients with severe mandibular ORN were examined histologically for the presence of necrotic margins and compared with clinical outcome of ORN persistence at follow-up. RESULTS: Median follow-up was 17.4 months. Eight specimens had histologic evidence of necrotic, nonviable bone at the margins of resections; however, there was no progression of disease among patients in this group. Twenty-six specimens were clear of necrotic margins; however, 8 patients from this group developed persistent disease. CONCLUSIONS: Irradiated mandible is susceptible to ORN progression even if clinical and final histopathologic assessments confirm complete resection of necrotic bone margins. Progression of disease in ORN is not related to inadequate resection of necrotic bone.

Safety and efficacy of maxillary labial frenectomy in children: A retrospective comparative cohort study.

BACKGROUND: Maxillary frenectomy in children is a common procedure, but concerns about scar tissue affecting diastema closure prevent many clinicians from treating prior to orthodontics. OBJECTIVES: To determine if maxillary frenectomy is safe and if diastema size is affected by early treatment. MATERIALS AND METHODS: Paediatric patients with hypertrophic maxillary frena were treated under local anaesthesia with diode laser and CO2 laser. Diastema width was compared by calibrating and digitally measuring initial and postoperative intraoral photographs. RESULTS: In total, 109 patients were included: 95 patients with primary dentition (39% male; mean age 1.9 years±1.5 years) and 14 with mixed dentition (43% male; mean age 8.1±1.3 years) with a mean follow-up of 18.0±13.2 months. No adverse outcomes were noted other than minor pain and swelling. In the primary dentition, a decrease in diastema width was observed in 94.7% with a mean closure of -1.4±1.0mm (range +0.7 to -5.1mm). In the mixed dentition, a decrease in diastema width was observed in 92.9% with a mean closure of -1.8±0.8mm (range 0 to -3.5mm). 74.5% of patients in the primary dentition and 75% of patients in the mixed dentition with preoperative diastema>2mm improved to<2mm width postoperatively. CONCLUSIONS: Frenectomy is associated with cosmetic and oral hygiene benefits and when performed properly, does not impede diastema closure and may aid closure. Technique and case selection are critical to successful outcomes. IRB ethics approval was obtained from Solutions IRB protocol #2018/12/8, and this investigation was self-funded.

The Value of Oxygen Desaturation Index for Diagnosing Obstructive Sleep Apnea: A Systematic Review.

OBJECTIVES: Intermittent hypoxemia is a risk factor for developing complications in obstructive sleep apnea (OSA) patients. The objective of this systematic review was to identify articles evaluating the accuracy of the oxygen desaturation index (ODI) as compared with the apnea-hypopnea index (AHI) and then provide possible values to use as a cutoff for diagnosing adult OSA. STUDY DESIGN: Systematic Review of Literature. METHODS: PubMed, the Cochrane Library, and SCOPUS databases were searched through November 2019. RESULTS: Eight studies (1,924 patients) met criteria (age range: 28-70.9 years, body mass index range: 21.9-37 kg/m2 , and AHI range: 0.5-62 events/hour). Five studies compared ODI and AHI simultaneously, and three had a week to months between assessments. Sensitivities ranged from 32% to 98.5%, whereas specificities ranged from 47.7% to 98%. Significant heterogeneity was present; however, for studies reporting data for a 4% ODI ≥ 15 events/hour, the specificity for diagnosing OSA ranged from 75% to 98%, and only one study reported the positive predictive value, which was 97%. Direct ODI and AHI comparisons were not made because of different hypopnea scoring, different oxygen desaturation categories, and different criteria for grading OSA severity. CONCLUSION: Significant heterogeneity exists in studies comparing ODI and AHI. Based on currently published studies, consideration should be given for diagnosing adult OSA with a 4% ODI of ≥ 15 events/hour and for recommending further evaluation for diagnosing OSA with a 4% ODI ≥ 10 events/hour. Screening with oximetry may be indicated for the detection of OSA in select patients. Further study is needed before a definitive recommendation can be made. Laryngoscope, 131:440-447, 2021.

Determinants of Sleep-Disordered Breathing During the Mixed Dentition: Development of a Functional Airway Evaluation Screening Tool (FAIREST-6).

Purpose: The purpose of this study was to identify patterns of functional, extraoral, and intraoral examination characteristics that correlate with increased risk of sleep disturbances and develop a functional airway screening tool to help clinicians for early diagnosis of pediatric sleep-disordered breathing. Methods: From March 2018 until March 2019, a cross-sectional study was conducted of 96 mixed dentition children during dental examinations at the UCLA pediatric dental clinic. Outcome measures included a sleep index score by the Sleep Disturbance Scale for Children (SDSC) completed by parents. Clinical assessment tool measurements assessing functional, extraoral, intraoral soft tissue, and intraoral hard tissue determinants were recorded during a routine dental examination by pediatric dental residents. Results: The mean age was 8.9 years (±1.9 years standard deviation), with 46 males and 50 females participating. Mouth-breathing (functional), mentalis strain (extra-oral), tonsillar hypertrophy and ankyloglossia (intraoral soft tissue), dental wear, and narrow palate (intraoral hard tissue) were found to be the most clinically deterministic of higher SDSC scores (P<0.01). A clinical assessment tool for sleep-disordered breathing in pediatric dental patients (FAIREST-6) was developed, comprising these six clinical factors. Conclusions: The FAIREST-6 is a concise and validated clinical assessment tool that may aid in early diagnosis and intervention of pediatric sleep-disordered breathing.

Determinants of probable sleep bruxism in a pediatric mixed dentition population: a multivariate analysis of mouth vs. nasal breathing, tongue mobility, and tonsil size.

OBJECTIVES: This study aims to identify structural and functional craniofacial characteristics that correlate with higher incidence of 'probable' sleep bruxism in children. METHODS: From March 2018 until March 2019, a cross-sectional clinical study was performed with ninety-six healthy children ages 6-12 years who presented for routine dental examination at the UCLA pediatric dental clinic. Variables of interest included: (1) assessment of probable bruxism based on parental awareness on the frequency of tooth grinding during sleep and clinical signs of bruxism based on tooth wear; (2) parental reports of mouth breathing while awake and asleep, snoring during sleep, difficulty breathing and/or gasping for air during sleep; (3) parental reports of psychosocial distress; (4) assessment of tonsil hypertrophy, tongue mobility, and nasal obstruction. Three pediatric dental residents were calibrated to perform the clinical data collection. All dental residents were graduated dentists with licensure and at least one year of experience examining children. The methodology to take the specific measurements administered in the manuscript were calibrated between the data-collectors under the supervision of a board-certified pediatric dentist and orthodontist (AY). RESULTS: The mean age of individuals was 8.9 (SD = 1.9) years with a gender distribution of 46 males and 50 females. There were 23 out of the 96 (24%) individuals who met the diagnostic criteria for probable sleep bruxism (PSB). Sleep Disturbance Scale for Children (SDSC) scores were significantly elevated among children positive for PSB, indicating that they are at higher risk for sleep disturbances (PSB-positive: 45.1 ± 13.0, PSB-negative: 34.8 ± 5.5; p < 0.0001). Impaired nasal breathing, parental reports of mouth breathing when awake or asleep, restricted tongue mobility, and tonsillar hypertrophy were found to be significant risk factors for PSB. Exploratory analysis further suggests a synergistic effect between tonsil hypertrophy, restricted tongue mobility, and nasal obstruction. The incidence of probable sleep bruxism among individuals without any of the exam findings of tonsillar hypertrophy, restricted tongue mobility, and nasal obstruction was 5/58 (8.6%), whereas the incidence of PSB among individuals with all three exam findings was 10/11 (90.9%), p < 0.0001. Among the 23 individuals with PSB, however, there were n = 5 (21.7%) who did not have any of the three exam findings, suggesting an additional role of psychosocial distress, postural maladaptation, malocclusion, or other factors in the etiology of sleep bruxism. CONCLUSION: This study shows that tonsil hypertrophy, restricted tongue mobility, and nasal obstruction may have a synergistic association on the presentation of PSB. Dentists should evaluate for tonsillar hypertrophy, restricted tongue mobility, and nasal obstruction in the evaluation of PSB, as these exam findings are highly prevalent in the majority of cases.

Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor.

OBJECTIVES: This study correlates objective and subjective measurements associated with obstructive sleep apnea (OSA) to define the efficacy of Distraction Osteogenesis Maxillary Expansion (DOME) to treat adult OSA patients with narrow maxilla and nasal floor. METHODS: This is a retrospective study reviewing cases from September 2014 through April 2018 with 75 eligible subjects. Inclusion criteria required OSA confirmed by attended polysomnography (PSG). Pre- and Post-operative clinical data were measured at the Stanford Sleep Medicine and Stanford Sleep Surgery Clinics. DOME is a two-step process starting with insertion of custom-fabricated maxillary expanders anchored to the hard palate by mini-implants followed by minimally invasive osteotomies. After maxillary expansion was complete, orthodontic treatment to restore normal occlusion was initiated. Perioperative Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Nasal Obstruction Symptom Evaluation (NOSE), and Oxygen Desaturation Index (ODI) were measured for 43, 72, 72, and 34 subjects respectively. Statistical analysis was performed using paired T-test with significance set at p-value < 0.05. RESULTS: The mean age of test subjects was 30.5 ± 8.5 years with a gender distribution of 57 males and 18 females. There was a significant reduction in pre and post-operative NOSE score (10.94 ± 5.51 to 3.28 ± 2.89, p < 0.0001), mean ESS score (10.48 ± 5.4 to 6.69 ± 4.75, p < 0.0001), and AHI (17.65 ± 19.30 to 8.17 ± 8.47, p < 0.0001) with an increased percentage of REM sleep (14.4 ± 8.3% to 22.7 ± 6.6%, p = 0.0014). No significant adverse effects were identified. CONCLUSIONS: DOME treatment reduced the severity of OSA, refractory nasal obstruction, daytime somnolence, and increased the percentage of REM sleep in this selected cohort of adults OSA patients with narrow maxilla and nasal floor.