Dental Asia May/Jun 2018

42 DENTAL ASIA MAY / JUNE 2018 Clinical Feature On this premise, the best place to start is how to assess the upper airway. Medical and Dental history, as always, is the initial clue provider, and in this regard questions about snoring, mouth, breathing, and teeth grinding are crucial. Issues with choking on food, troubles with chewing and breathing at the same time are also useful clues. The relevance of all of these symptoms will be clariƤed in the subsequent discussion. Clinical Examination The next stage in clinical assessment is the examination. The Ƥrst impression is to simply look at the patient before you. Do they have an open mouth posture for their breathing? Can you hear thembreathing (the “Darth Vader” noise, that is clinically known as stertor)? As you then look inside the mouth, apart from the dental health, are there malocclusions, altered facial bone development, a high arched palate, evidence of grinding or suggestion of reƪux damage to the teeth. The next step is to look beyond the teeth: Is there a tongue tie? How big is the tongue relative to the space of the oral cavity? And then Ƥnally, what is the size and position of the tonsils? With respect to the tonsils, the important issue is the space between them, as this is the functional area of the transitional space from mouth to oropharynx. Sleep Apnoea and Bruxism Armedwith awealth of this information, dentists Ƥnd themselves in the privileged position of being able to alter the course of a patient’s life, for the better. Let’s start with children. To be absolutely clear on thismatter, a starting point that is important to realise is children are not supposed to snore, mouth breathe, or grind their teeth. Habitual snoring, which is deƤned as snoring four nights of theweek ormore, is nowclassiƤed as being part of the spectrumof paediatric sleepdisorderedbreathing, with the extreme of this spectrumbeing sleep apnoea. With respect to mouth breathing, this is brought about as a response to obstructed nasal breathing inmore than 90% of cases and should not be written o ơ as a habit. The main cause of obstructed nasal breathing is enlarged adenoids, something that can be assessed through taking x-rays – Orthopantomogram (OPG/ Panoramic), Lateral Cephalometric (Lat. Ceph.) and cone beam computed tomography (CBCT)- with the next most common cause being enlarged turbinates related to allergy (again, this is evident on OPG andmore so on cone beamCT). Childrenwith nasal obstruction have breathing di ƥ culties, and this can impact their cardio- respiratory physiology to the point that they can develop a serious medical condition calledpulmonaryhypertension. Hence, it is important not to dismiss such clinical presentations. With respect to bruxism, more and more studies are showing an association with sleep disordered breathing, and in children there is literature indicating an 80% resolution of bruxism, after their airway obstruction has been addressed. Large adenoids Enlarged nasal turbinates Facial Growth and Developmental Factors There is a debate in literature regarding the interplay between nasal obstruction, resultant mouth breathing, and subsequent aberrations in facial growth and development. In order to help address this question, we need a greater understanding intowhat inƪuences facial growth and development. In its simplistic form, it is a combination of genetic and epigenetic programming on how things develop, susceptibility to abnormal