Research Article

Knowledge about Child Sleep Among Dentists. A Perception of Dentists about the Knowledge Acquired on the Subject at Dental School: A Pilot Study

Lívia Versiani¹*, Bianca Diniz² and Thaís Pedroso³

¹Doctor in Health Science, Brasília University, Orthodontist Professor- Hodos -Uningá, Brazil

²Pediatric Dentist and Orthodontist, Hodos -Uningá, Brazil

³Orthodontist Hodos -Uningá, Brazil. Responsible for Collecting Study Data, Brazil

Submission: January 04, 2024; Published: January 17, 2024

*Corresponding author: Lívia Versiani, Doctor in Health Science, Brasília University, Orthodontist Professor- Hodos -Uningá, Brazil

How to cite this article: Lívia Versiani*, Bianca Diniz and Thaís Pedroso. Knowledge about Child Sleep Among Dentists. A Perception of Dentists about the Knowledge Acquired on the Subject at Dental School: A Pilot Study. Adv Dent & Oral Health. 2023; 17(2): 555956. DOI: 10.19080/ADOH.2024.17.555956

Abstract

Obstructive sleep apnea syndrome is one of the main disorders affecting children and adults. The aim of this study was to evaluate, using a questionnaire, the opinion of a group of dentists about the knowledge they acquired during dental school about sleep and sleep disorders linked to dentistry. The questionnaire was answered by 200 dentists. As a result, there was a lack of knowledge about sleep in childhood, indicating the importance of the subject for professionals and broader training in sleep, so that they can treat their patients fully. The subject is still little explored in educational institutions, thus limiting clinical practice.

Keywords: Sleep; Child; Sleep apnea; Childhood snoring; Breathing disorders

Abbreviations and Acronyms: OSA: Obstructive Sleep Apnea; OSAS: Obstructive Sleep Apnea Syndrome; UAV: Upper Airway PSG: Polysomnography; MAD: Mandibular advancement device; RME: Rapid maxillary expansion

Introduction

Sleep is a vital and restorative process for the body and brain, essential for children’s growth and development. Obstructive sleep apnea (OSA) is a breathing disorder caused by obstruction of the upper airways (UA), which can be partial or complete. Its main characteristic is interrupted sleep and difficulty breathing during sleep [1]. Early identification is crucial, thus preventing complications for the patient, since there is the possibility of triggering various cardiovascular disorders hypertension, metabolic disorders, neuropsychiatric disorders respiratory disorders, behavioral problems and growth deficiency [2]. The aim of this article is to address sleep disorders and show data from a survey, carried out by means of a questionnaire, on the degree of knowledge of dental professionals during their undergraduate studies.

Literature Review

By identifying OSA and starting treatment, it is possible for the child to develop well in craniofacial formation. Early diagnosis of OSA is made through clinical examinations, anamnesis and polysomnography (PSG) [3]. During screening, the anamnesis should be conducted in such a way as to identify sleep disorders to obtain important information such as simple snoring, daytime sleepiness, lack of attention, hyperactivity, irritability or even fatigue [4]. Some studies have shown that maxillary expansion improves sleep quality and, consequently, airway quality, providing patients with good breathing. Early treatment with orthodontists is extremely important for the stability of OSA throughout growth. The orthopedic effect of rapid maxillary expansion helps to increase the space for the passage of air in the nasopharyngeal region (Melo R, 2023).

Bruxism is also a sleep disorder whose main characteristic is teeth grinding. Although it has various definitions, it is divided into nocturnal and daytime [5]. A short lingual frenulum can interfere not only with breastfeeding, but also with speech, facial, dental and bone position. It directly affects the formation of the upper airways (Heit, 2022). Snoring occurs due to airflow obstruction. It is caused by a collapse of the pharynx which blocks the air passage, causing vibrations. This symptom is often not taken seriously by parents, as many are unaware of the serious future complications [6,7]. Obesity is also an important risk factor for OSA in children and adults. Mechanisms of the contribution of obesity are related to the presence of fat at the level of the pharynx, as well as abdominal obesity, which decreases respiratory function (Heit, 2022). Other risk factors for OSA besides snoring and obesity that also require attention are frequent upper airway inflammation, allergic rhinitis, adenoid hypertrophy and tonsillitis [1,6,8].

Methodology

This study was carried out by collecting data using a virtual questionnaire. The aim was to identify dentists’ prior knowledge of infant sleep-in dentistry and their interest in the proposed topic. A literature review was carried out with articles acquired by searching PubMed, Google Scholar and Medline. Using the study tools, key words were searched for: sleep, child, sleep apnea, child snoring, child snoring treatment and child apnea treatment. Fortythree articles related to the topic were found. Data collection took place in June and July 2020. The questionnaire was applied via Google Docs, shared via a virtual access link, sent via email, social networks and messaging apps. Participants in this study were dentists who had graduated and were registered with the Regional Council of Dentistry (CRO), with the following specialties: pediatric dentistry, orthodontics and other specialties. The questionnaire was made up of seven questions, with the option to choose only one answer: yes or no. At the end of the questionnaire, participants could suggest the subject they would like to understand better about children’s sleep in dentistry (Figure 1).

Results

The results of this study, which involved 200 questionnaires sent to dentists from different areas, showed that 39% of the sample were orthodontists, 14.5% pediatric dentists and 12% in training in both orthodontics and pediatric dentistry. The other participants were divided into different areas of dentistry, as shown in Graph 1. Graph 2 shows that 85.5% of the participants reported that they had no knowledge of sleep-in dentistry during their undergraduate studies. Despite this, 62.5% made a habit of investigating their patients’ sleep during the anamnesis (Graph 3). According to Graph 4, 99% of the participants considered the subject to be important for training in the area during their undergraduate studies. However, 43.5% were unaware of the sleep disorders that affect children (Graph 5). Graph 6 shows that 99% of the participants felt it was necessary to learn about the role of dentists in treating snoring and sleep apnea and 98.5% were interested in learning about bruxism in children (Graph 7).

Discussion

According to the results obtained in the questionnaire, there is a clear lack of knowledge on the part of professionals about the correct diagnosis and treatment options for OSA. The dental surgeon who deals with children should be one of the first professionals to receive, diagnose, treat and/or refer children to multidisciplinary sleep teams. In the clinical examination of children with OSA, important changes in the dentition, mandible, maxilla, tongue, adenoids, tonsils, hard and soft palate should be observed, since all these structures are interconnected for good health and, consequently, good breathing in adults and children (KEVIM, 2019) [9]. According to Tamasas [2], mouth breathing and dry mouth are present in 95% of children with OSAS, which leads to a deficiency in saliva production, leaving the oral region prone to cavities and periodontal diseases. Studies show that the upper airways and systemic inflammation are involved in the pathophysiology of children with OSA. The increase in inflammatory mediators found in the tonsils can lead to a recurrent infectious condition in the pediatric population [2,8].

Surgical treatment is considered the first choice for children and adolescents with OSA, when there is a surgically correctable airway obstruction responsible for the apnea, removal of the adenoid and tonsils. [10]. Changing the quality of life is the first step, since obesity is a risk factor in both adults and children. By modifying eating habits with the help of a nutritionist and practicing daily physical exercise, patients can eliminate excess fat in important structures in the respiratory process and reduce systemic inflammation. Changing habits contributes to an improvement in your overall health. Kevin, (2019) shows that CPAP is also used as an aid in the treatment of children and adults with OSA. This non-invasive equipment facilitates breathing during sleep by reducing respiratory work and releasing respiratory pressure. Generally, patients who use CPAP have difficulty adapting at the beginning of treatment. Studies show that rapid maxillary expansion (RME), using orthopedic appliances, which have the function of separating the median palatine suture and circummaxillary sutures, increasing the transverse diameter of the hard palate, the volume of the airways and nasal cavity, and in the nasopharyngeal area, lead to an improvement in the position of the tongue and the passage of air, thus improving breathing in mild and moderate cases of OSA in children according to [11].

It is worth noting that both adenoid and tonsil surgical procedures and MRE significantly improve the quality of life, concentration and attention of children who have breathing disorders during sleep, reducing complaints related to apnea and snoring, according to [12]. However, we must consider that to perform an RME, there must be orthodontic indications such as: high and narrow palate, deciduous dentition, mixed or permanent dentition in children and young people, dental crowding, deep bite, posterior crossbite [13]. In young adults, MRE has been increasingly performed with the aid of mini-implants such as anchorage, Mini-implant Assisted Rapid Palatal Expansion (MARPE) and studies show treatment success [3,8]. Increasingly, studies show that orthopedic appliances for advancing the mandible are effective in children with OSA, since when evaluating cephalometric measurements and comparing before and after, a significant increase in the upper airway has been observed [14- 25]. It should be borne in mind that the time of use must be individual for each patient, for example, CL I Angles patients will not have the same use protocol as a CL II Angles patient, who needs continuous use for better results in muscle stability, benefits for the mandible and increased posterior airway space (LIMA, 2023). Maniglial, (2022) studies the effectiveness of combined treatment with oral appliances and treatments for nasal obstruction [26- 42]. The results indicate a significant improvement in sleep apnea symptoms in patients receiving combined treatment.

Conclusion

The survey showed results that lead us to conclude that dentists still lack a great deal of knowledge about children’s sleep. The participants themselves left comments with various doubts on the subject. This reinforces the fact that sleep disorders should be increasingly studied and put into practice, since a simple intervention in childhood contributes to good health and quality of life well into adulthood. A reflection on the subject is expected from the evaluation of the results [43-46]. Future studies are needed so that new educational strategies can be implemented and allow students to gain a deeper understanding of this subject. In this way, after graduating, they will be able to act comprehensively in caring for children’s general health, being able to treat sleep disorders related to dentistry..

References

1. Gulotta G, Giannicola I, Claudio V, Antonella P, Antonio G (2019) Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of The Art. Int J Environ Res Public Health 16(18): 3235.
2. Tamasas B, Travis N, Maida C (2019) Oral Health and Oral Health-Related Quality of Life in Children with Obstructive Sleep Apnea. J Clin Sleep Med 15(3): 445-452.
3. Perin MAA, Viviane Maria GF, Jônatas BA, Cíntia Meirelles CK, Gustavo M, et al. (2020) Expansão Rápida Da Maxila Assistida Por Mini-Implantes (Marpe) Em Chen, V. G. Et. Al. Inflammatory Markers in Palatine Tonsils of Children with Obstructive Sleep Apnea Syndrome. Braz J Otorhinolaryngol 86(1): 23-29.
4. Marino A, Nota A, Caruso S, Gatto R, Malagola C, et al. (2021) Obstructive Sleep Apnea Severity and Dental Arches Dimensions in Children with Late Primary Dentition: An Observational Study. Cranio 39(3): 225-230.
5. Lobbezoo F, Ahlberg J, Raphael KG, Wetselaar P, Glaros AG, et al. (2018) International Consensus on The Assessment of Bruxism: Report of A Work in Progress. J Oral Rehabil 45(11): 837-844.
6. Sun K, Yan G, Yue Z, Xiubo J (2019) Breastfeeding and Risk of Habitual Snoring in Children: A Metaanalysis. Matern Child Nutr 15(3): e12799.
7. Tan YH, Choon How H, Yoke Hwee C, Oon HT (2020) Approach to The Snoring Child. Singapore Med J 61(4): 170-175.
8. Chang H, Yu-Feng C, Je-Kang D (2020) Obstructive Sleep Apnea Treatment in Adults. Kaohsiung J Med Sci 36(1): 7-12.
9. Silva PRE (2019) Avaliação Comparativa Das Características Oclusais De Crianças Com Síndrome Da Apneia Obstrutiva Do Sono (Saos) Apresentando Ou Não Atresia Transversal Da Maxila. Universidade Federal De Uberlândia Faculdade De Odontologia, Uberlâ
10. Oliveira Cs, Bruna Vanessa MF, Raiane Araujo Soares AV, Júlia Maria MF, Isabelle Tenório DA (2023) Alterações Anatômicas Da Naso-Orofaringe Como Etiologia Da Apneia Do Sono: Uma Revisão De Fisiopatologia E Abordagens Cirúrgicas Da Sídrome Recima 4(4).
11. Súcar AMS, Borja Sánchez-Súcar F, José-Manuel AS, Vanessa PG, José-María M, et al. (2019) Effect of Rapid Maxillary Expansion on Sleep Apnea-Hypopnea Syndrome in Growing Patients. A Meta-Analysis. J Clin Exp Dent 11(8): e759-e767.
12. Gonçalves LPV (2012) Qualidade De Vida De Crianças Com Distúrbios Respiratórios Do Sono Após Expansão Rápida Da Maxila. Brasília: Universidade De Brasí
13. Gozal D, Hui-Leng T, Leila KG (2020) Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision. J Clin Med 9(3): 888.
14. Pacheco MCT, Bruna Santos F, Nathalia Silveira F, Maria Teresa MA (2015) Craniofacial Changes and Symptoms of Sleep-Disordered Breathing in Healthy Children. Dental Press J Orthod 20(3): 80-87.
15. Waters T (2019) Alternative Interventions for Obstructive Sleep Apnea. Cleve Clin J 86(9 Suppl 1): 34-41.
16. (2016) Pacientes Adultos. Universidade Federal Do Paraná, Curitiba .
17. Harneet KW (2019) Beyond Heart Health: Consequences of Obstructive Sleep Apnea. Cleve Clinic J Med 86(9 Suppl 1): 19-25.
18. Campanholo MAT, Fabio De Azevedo C, Renato S, Leonardo H, Lia Rita Azeredo B, et al. (2019) Dysphagia in Patients with Moderate and Severeobstructive Sleep Apnea. Braz J Otorhinolaryngol 87(4): 422-427.
19. Cunha TCA, Thais Moura G, Fernanda RA, Fernanda LMH, Luciana BMG, et al. (2020) Using Craniofacial Characteristics to Predict Optimum Airway Pressure in Obstructive Sleep Apnea Treatment. Braz J Otorhinolaryngol 86(2): 174-179.
20. Norman MB, Henley CH, Karen AW, Colin ES (2019) Snoring and Stertor are Associated with More Sleep Disturbance Than Apneas and Hypopneas in Pediatric SDB. Sleep Breathing 23(4): 1245-1254.
21. Stangenes KM, Mari H, Irene Bircow E, Thomas H, Trond M, et al. (2019) Sleep Problems, Behavioural Problems and Respiratory Health in Children Born Extremely Preterm: A Parental Questionnaire Study. Bmj Paediatrics Open 3(1): e000534.
22. Xu Z, Yunxiao W, Jun T, Guoshuang F, Wentong G, Zheng L (2020) Risk Factors of Obstructive Sleep Apnea Syndrome in Children. J Otolaryngol Head Neck Surg 49(1): 11.
23. Zaffanello M, Giuseppe L, Nazzarena A, Michele P, Laura T, et al. (2019) Popularity of Sleep Disordered Breathing in Childhood: An Analysis of Worldwide Search Using Google Trends. Transl Pediatr 8(5): 383-390.
24. Savini S, Ciorba A, Bianchini C, Stomeo F, Corazzi V, et al. (2019) Assessment of Obstructive Sleep Apnoea (Osa) In Children: An Update. Acta Otorhinolaryngol Ital 39(5): 289-297.
25. Heffernan A, Uzair M, Russell C, Shaun Yo, Indra N, et al. (2019) Transition to Adult Care for Obstructive Sleep Apnea. J Clin Med 8(12): 2120.
26. Marklund M, Marc JA Braem, Johan V (2019) Update on Oral Appliance Therapy. Eur Respir Ver 28(153): 190083.
27. Rundo JV (2019) Obstructive Sleep Apnea Basics. Cleve Clin J Med 86(9 Suppl 1): 2-9.
28. Zerg G, Yaoshu T, Jin Z, Darong Z, Bin Y, et al. (2018) Clinical Application of MRI-Respiratory Gating Technology in The Evaluation of Children with Obstructivewithep Apnea Hypopnea Syndrome. Med (Baltimore) 97(4): e9680.
29. Gipson K, Mengdi L, Bernard TK (2019) Sleep-Disordered Breathing in Children. Published In Final Edited Form As: Pediatr Rev 40(1): 3-13.
30. Durhan M, Agrali OB, Kiyan E, Bas Ikizoglu N, Ersu R, et. al. (2019) Does Obstructive Sleep Apnea Affect Oral and Periodontal Health in Children with Down Syndrome? A Preliminary Study. Niger J Clin Practice 22(9): 1175-1179.
31. Yanyan M, Yu Min, Xuemei G (2019) Mandibular Advancement Appliances for The Treatment of Obstructive Sleep Apnea In Children: A Systematic Review And Meta-Analysis. Sleep Med 60: 145-151.
32. Wang J, Yu Z, Wen Y, Tian S, Pei X, et al. (2019) Correlations Between Obstructive Sleep Apnea and Adenotonsillar Hypertrophy in Children of Different Weight Status. Scientific Reports.
33. Hanlon CE, Edem B, Jefferey SG, Laura MS, Tammy MB (2019) The Association of Obstructive Sleep Apnea and Left Ventricular Hypertrophy in Obese and Overweight Children with History of Elevated Blood Pressure. J Clin Hypertens 21(7): 984-990.
34. Otavio RV, Caroline Rodrigues L, Thaila Corsi D, Braulio Henrique Magnani B, Michelle Cardoso M, et al. (2019) Influência Da Massa Magra Na Apnéia Do Sono Em Crianças E Adolescentes Com Excesso De Peso: Resultados Parciais.
35. Schutz TCB, Gladys CD, Marcia PH, Thays CAC, Serigo T (2011) Class II Correction Improves Nocturnal Breathing in Adolescents. Angle Orthod 81(2): 222-228.
36. Pirelli P, Maurizio S, Christian G (2016) Rapid Maxillary Expansion (RME) For Pediatric Obstructive Sleep Apnea: A 12-Year Follow-Up. Sleep Med 16(8): 933-935.
37. Christian Guilleminault, Shehlanoor Huseni, Lauren Lo (2016) A Frequent Phenotype for Paediatric Sleep Apnoea: Short Lingual Frenulum. ERJ Open Res 2(3).
38. Mazzarolo L (2014) Bionator Ufsc: Fundamentos E Protocolo Clínico De Tratamento. Universidade Federal De Santa Catarina Curso De Graduação Em Odontologia, Florianó
39. Walter RN, David G, Renata C (2019) Cephalometric and Pharyngometric Evaluation in Snoring Children with Sleep-Disordered Breathing and Adenotonsillar Hypertrophy, Under an Orthodontic or Orthopedic Treatment. J Child Sci 9:1-7.
40. Bazargani F, Anders M, Björn L (2018) Effects on Nasal Airflow and Resistance Using Two Different RME Appliances: A Randomized Controlled Trial. Eur J of Orthod 40(3): 281-284.
41. Ennes J, Alberto C (2004) Sutura Palatina Mediana: Avaliação Do Grau De Ossificação Em Crânios Humanos. Dental Press Ortodon Ortop Facial 9(5).
42. Katyal V, Yvonne P, James AM, Cathal D, Declan JK, et al. (2013) Craniofacial and Upper Airway Morphology in Pediatric Sleep-andordered Breathing: Systematic Review and Meta-Analysis. Am J Orthod Dentofacial Orthop 143(1): 20-30.
43. Avis KT, Karen LG, David CS (2015) Obstructive Sleep Apnea Syndrome (Osas) Increases Pedestrian Injury Risk in Children. J Pediatr 166(1): 109-114.
44. Costa AL, Denise M, Cláudia S, Gabriel K, Sekine L, et. Al. (2018) The Effect of Mandibular Distraction Osteogenesis on Airway Obstruction and Polysomnographic Parameters in Children with Robin Sequence. J Cranio-Maxillo-Facial Surgery 46(8): 1343-1347.
45. Cunha DA. Et. Al. (2011) Effects of Oral Breathing in The Nutritional State. Why Does It Happen? Arq Int Otorrinolaringol / Intl Arch Otorhinolaryngol, São Paulo - Brasil.
46. Hakan E, Juan Martin P (2011) Airway Volume for Different Dentofacial Skeletal Patterns. Am J Orthod Dentofacial Orthop 139(6): e511-521.