Important Study Points Out A Developmental Link That Leads To Sleep Apnea And Headache Problems In Adults. Tonsil And Adenoid Removal Does Not Correct The Developmental Defects They Cause.

    GURNEE, IL, January 24, 2010 /24-7PressRelease/ -- An incredibly important study in the International Journal of Pediatric Otorhinolaryngology explains the changes that take place in children with impaired breathing secondary to enlarged tonsils and adenoids. This study showed that even though the tonsils and the adenoids are removed they leave permanent residual defects that must be addressed. This study will probably be ignored by most news outlets because understanding the significance requires advanced knowledge in Sleep Medicine, Dentistry and Neurology.

This article will attempt to explain the significance. Enlarged tonsils and adenoids creating a breathing problem in pediatric patients. This nasopharyngeal breathing problem can lead to snoring and sleep apnea and must be addressed for the current health of the child. Sleep apnea has been shown to be present in 80% of Children with Attention Deficit disorders and Hyperactivity. In addition to ADD and ADHD it may also cause dyslexia, learning disabilities and behavioral disorders. Time is of the essence and children with snoring should always be evaluated for sleep apnea as soon as possible. Delayed brain development and permanent chages in brain evelopment can occur with untreated pediatric sleep apnea. There is good news because a new study in the American Journal of Respiratory and Critical Care Medicine, may lead to a simple urine test to help diagnose obstructive sleep apnea in children by screening for a group of specific proteins. These proteins are present in the urine of children with obstructive sleep apnea (OSA). "These findings open up the possibility of developing a relatively simple urine test that could detect OSA in snoring children. This would alleviate the need for costly and inconvenient sleep studies in children who snore, only about 20% to 30% of whom actually have OSA," says researcher David Gozal, MD, professor and chairman of the pediatrics department at the University of Chicago.

Watching and waiting to see if tonsils and adenoids will shrink is unacceptable if there is any evidence of sleep apnea because of possible lifetime adverse effects. In addition to causing sleep apnea children with enlarged tonsils and adenoids frequently have structural problems that occur. The current study concludes "Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended." This is extremely important because the narrow maxillary arch will also restrict the nasopharyngeal airway as well as the interfere with normal growth of the oral structures. Experimental studies by Egil Harvold and others have shown negative changes in growth and development that effects the entire body.

The same changes that occur lead to the development of craniomandibular disorders or TMJ disorders. The National Heart Lung and Blood Institute (NHLBI) of the NIH considers Sleep Apnea to be a TMJ disorder. Their report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS " discusses how heart attacks and strokes and other cardiovascular consequences can result from sleep apnea. These patients frequently (usually) have oral structures similar to those describe in the article. The article suggests that orthodontic collaboration is necessary in treating these patients.

Adult patients with sleep apnea are not an accident, but rather the end of a long developmental pathway. CPAP is still considered the Gold Standard for treating sleep apnea but in the last several years oral appliance therapy has seen exponential growth. That is because patient compliance with CPAP is very low. A common comment heard is "I HATE CPAP!" and this was the reason for the creation of an excellent website with extensive information on sleep apnea http://www.ihatecpap.com . A recent study showed 60% of patients abandon CPAP use and even patients who use it average only 4-5 hours a night not the recommended 7- 7 1/2 hours a night. Oral appliances work by increasing the volume of the mouth and bring the tongue and lower jaw forward to increase airway space. Patients that have narrow maxilla as described in this new article frequently have insufficient room for their tongue which then falls back and blocks the airway. Learn more about oral appliances at http://www.ihatecpap.com/oral_appliance.html

The same developmental characteristics that lead to TMJ disorders are also responsible for the vast majority of migraines and tension headaches. The stomatognathic system includes the jaw joints (Temporomandibular Joints or TMJ), the jaw muscles and structures and most importantly the trigeminal nerve. The trigeminal nerve or dental nerve is responsible for almost all migraines and most tension type headaches. To understand the significance it is responsible for approximate half of the total input into the brain. When the mouth teeth, jaw muscles and jaw joints do not work together in a unified manner the system tries to adapt. TMJ disordrs and headaches are actually signs of repetitive strain type injury as adaptation fails. This is often compromised by airway issues. The single most important function of the jaws is to maintain an airway which is essential to life.

When the system is not well correlated it leads to nociceptive inputs into the central nervous system which create pain. In computer lingo this would be known as Garbage in - Garbage out. Garbage out is TMD including migraines. The trigeminal nerve controls the blood flow to the anterior 2/3 of the meninges of the brain and is the most common cause of migraine type headaches. The Chronic Daily Headaches, Tension Type Headaches, Sinus Headaches and Episodic Tension Type Headaches are also mediated by the trigeminal nerve which innervates the lining of the sinuses and the jaw muscles. Neuromuscular Dentistry is explained in simple terms in Sleep and Health Journal (http://www.sleepandhealth.com/neuromuscular-dentistry) is used to reduce referred pain from masticatory muscles to prevent, eliminate and/or alleviate both migraines and tension type headaches by restoring balance to the Neuromuscular System. Http://www.ihateheadaches.org explains the importance of Neuromuscular Dentistry in treating all types of headaches. TMJ disorders are often called "THE GREAT IMPOSTER" because they are so frequently misdiagnosed. "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" is a must read for all patients with chronic headaches, migraines or TMJ disorders and can be found in Sleep and Health Journal at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor.

The following is taken from www.ihateheadaches blog:
"Chronic Daily Headache in Children and Adolescents
Chronic Daily Headache which affects 2-4% of female adolescents and as high as 2% of males can have a devastating effect on children. They usually occur with a chronic baseline headache with episodes of severe migraine-like are severe in intensity. This condition can last for months and there is no known underlying pathology. A neuromuscular dentist (NEUROMUSCULAR DENTISTRY http://www.sleepandhealth.com/neuromuscular-dentistry) should evaluate these patients early in treatment after organic disease is ruled out. Children are experiencing numerous changes at this period of their life including changes in hormonal status, increase peer pressures in school as well as increasing demands from school. They are also frequently going thru transitional dentition.

The advantage to orthotic treatment is there is at least a 50-80% improvement in the majority of patients treated with an orthotic. Even this partial relief could be life changing. If there is a primary problem related to jaw function and/or trigeminal nerve function Neuromuscular Dentistry allows early correction and orthodontics for case completion. It must be recognized that this condition frequently begins during orthodontic treatment.

Children with Chronic Daily Headache (CDH) problems have associated symptoms including sleep disturbances, other pain problems, dizziness that frequently results in school absence. Temporomandibular disorders are also known to cause severe Tension-Type headaches as well as other symptoms including facial pain, neck pain dizziness, ear pain, stuffy ears , sinus pain and sleep disorders. The National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder in their report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" The report defines The term TMD as "a collection of MEDICAL and dental conditions affecting the temporomandibular joint (TMJ) and/or muscles of mastication, as well as contiguous tissue components. Symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function. The masticatory apparatus is not only involved in chewing and swallowing but also in other critical tasks, including breathing and talking. This is not a dental problem but a medical problem that can cause wide spread problems including Migraines, Chronic Daily Headaches, Episodic Tension Type Headaches and Morning Headaches.

CDH is frequently associated with medication-overuse headache which is a bigger problem in children than adults as it can lead to a lifetime pattern of overuse. CDH is known to have "psychiatric comorbidity (anxiety and mood disorders) these may be a direct result of living with severe pain but may also be do to sleep apnea or other sleep disorders such as primary insomnia that is suspected as an etiology for central sensitization. The NHLBI report states " Pain linked to the TMJ and/or muscles of mastication constitutes the essential criterion for case assignment. It often qualifies as "aching", "throbbing", "tiring" and exhausting. About 60-90% of cases appear to experience satisfactory resolution of symptoms with a range of interventions. In contrast, the remaining group of patients does not respond well to these treatments and continues to exhibit persistent pain. Comorbid complaints, such as problems with sleep, blood pressure and breathing are not uncommon for this group of TMD patients but have not been well characterized. " The report of 60-90% relief is astounding compared to reports from neurological journals. Cases should be evaluated for TMD by a neuromuscular dentist for early treatment to lower the risk of developing central sensitization and a lifetime of chronic headaches and/or migraines. While there is a group reported to not respond to treatment it is a minority of patient.

This view is supported by Dr Barry Cooper in his paper " Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment." published in Cranio in April 2009. He reported "there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type". Dr Cooper reported " Evidence for a cause and effect relationship was strong." The paper concluded that "TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition." Early treatment to prevent progression is the ideal but relief of symptoms for 60-90 % of children as reported by the NHLBI would be sufficient to warrant evaluation of all pediaric and adolescent headaches.

Another paper in Cranio by Cooper BC, Kleinberg I. "Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients." reported Patients reported "overwhelming symptom relief" This study was based specifically on neuromuscular dental treatment and the results were overwhelming including "reduction of headaches and other pain symptoms." Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

Unfortunately both adult and pre-adult patients are often not referred for neuromuscular dental evaluation for numerous reasons. A surprising reason is that physicians are not comfortable referring to dentists. This is beginning to change as physicians see excellent results of treatment of sleep apnea with oral appliances (http://www.ihatecpap.com/oral_appliance.html) and the medical community recognizes the effects of periodontal disease on chronic inflamation, cytokines and the cardiovascular effects of these changes."

Pub Med Abstracts are included below:
Int J Pediatr Otorhinolaryngol. 2009 Nov 23. [Epub ahead of print]
Development of craniofacial and dental arch morphology in relation to sleep disordered breathing from 4 to 12 years. Effects of adenotonsillar surgery.
Löfstrand-Tideström B, Hultcrantz E.

Department of Surgical Sciences, Division of Otorhinolaryngology, University of Uppsala, SE - 751 85 Uppsala, Sweden.
OBJECTIVES: To study the development of craniofacial and dental arch morphology in children with sleep disordered breathing in relation to adenotonsillar surgery. SUBJECTS AND METHODS: From a community-based cohort of 644 children, 393 answered questionnaires at age 4, 6 and 12 years. Out of this group, 25 children who were snoring regularly at age 4 could be followed up to age 12 together with 24 controls not snoring at age 4, 6 and 12 years. Study casts were obtained from cases and controls and lateral cephalograms from the cases. Analysis regarding facial features and dento-alveolar development was performed. RESULTS: Children snoring regularly at age 4 showed reduced transversal width of the maxilla and more frequently had anterior open bite and lateral cross-bite than the controls. These conditions persisted for most cases at age 6, by which time 18/25 had been operated for snoring. In most of the cases, surgery cured the snoring temporarily, but their width of the maxilla was still smaller by age 12-even when nasal breathing was attained. At age 12, the frequency of lateral cross-bite was much reduced and anterior open bite was resolved, both in cases and controls. The children who snored regularly at age 12 operated or not operated, showed a long face anatomy and were oral breathers (this applied even to those who were operated). The seven cases who were not operated and the five who were still snoring in spite of surgery at age 12, did not have reduced maxillary width as compared to the controls. CONCLUSION: Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended.

PMID: 19939470 [PubMed - as supplied by publisher]

Rev Neurol (Paris). 2009 Jun-Jul;165(6-7):521-31. Epub 2008 Nov 28.
[Management of chronic daily headache in children and adolescents]
[Article in French]

Cuvellier JC.

Service de neuropediatrie, clinique de pediatrie, hôpital Roger-Salengro, centre hospitalier regional et universitaire de Lille, rue du Professeur-Laine, 59037 Lille cedex, France. [email protected]
Chronic daily headache (CDH) affects 2 to 4% of adolescent females and 0,8 to 2% of adolescent males. CDH is diagnosed when headaches occur more than 4 hours a day, for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent headaches, that are migraine-like, as well as a chronic baseline headache. Silberstein and Lipton divided patients into four diagnostic categories: transformed migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. The second edition of the International Classification of Headache Disorders did not comprise any CDH category as such, but provided criteria for all four types of CDH: chronic migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Children and adolescents with CDH frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache and a psychiatric comorbidity (anxiety and mood disorders). CDH frequently results in school absence. CDH management plan is dictated by CDH subtype, the presence or absence of medication overuse, functional disability and presence of attacks of full-migraine superimposed. Reassuring, explaining, and educating the patient and family, starting prophylactic therapy and limiting aborting medications are the mainstay of treatment. It includes pharmacologic (acute and prophylactic therapy) and nonpharmacologic measures (biobehavioral management, biofeedback-assisted relaxation therapy, and psychologic or psychiatric intervention). Part of the teaching process must incorporate life-style changes, such as regulation of sleep and eating habits, regular exercise, avoidance of identified triggering factors and stress management. Emphasis must be placed on preventive measures rather than on analgesic or abortive strategies. Stressing the reintegration of the patient into school and family activities and assessing prognosis are other issues to address during the first visit. There are limited data evaluating the outcome of CDH in children and adolescents.

Cranio. 2009 Apr;27(2):101-8.
Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology of the State University of New York (SUNY) Stony Brook School of Dental Medicine, NY, USA. [email protected]
A prominent etiological theory proposed for TMD related headache is that it results from a dysfunctional masticatory muscle system, wherein muscle hyperactivity is frequently caused by dental temporomandibular disharmony. The central goal of this article was to determine from a literature review of the subject whether there is significant evidence to support a relationship between headaches and TMD prevalence. A second purpose was to determine from such a review whether any relationship was one of cause and effect and whether treatment of the TMD condition can result in meaningful reduction or resolution of headaches. In the literature, there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type. Evidence for a cause and effect relationship was strong. It generally showed in numerous patients that TMD treatment of a large number of patients resulted in significant improvement in the physiological state of the masticatory system (muscles, joints and dental occlusion). Reduction or resolution of muscle tension-type headaches that were present was clinically significant. The authors concluded that TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition.

PMID: 19455921 [PubMed - indexed for MEDLINE]

Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. [email protected]
Comment in:

Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH, and has a Dental Practice with his partner Dr Mark Amidei. He has recently formed Chicagoland Dental Sleep Medicine Associates. He is a Regent of ICCMO and its representative to the TMD Alliance, He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management, a graduate of LVI. He is a former assistant professor at Rush Medical School's Sleep Service where he worked with Dr Rosalind Cartwright who is a founder of Sleep Medicine and Dental Sleep Medicine. Dr Shapira is a consultant to numerous sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.

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