GAP Australasian Dentist Mar Apr 2020

Category Austr°l°si°n Dentist 73 a diagnosis that benefits significantly from early treatment 10 . Asymmetry has been demonstrated in 73% of cases with tonsillar lymphoma, with the probability of lymphoma 43 times more likely in the presence of asymmetry. °n a normal paediatric population, the presence of asymmetric tonsils with other signs of malignancy increases the likelihood 8938-fold 11 . °herefore, rapidly progressive tonsillar enlargement and/or asymmetry warrants a high degree of suspicion 9 and should prompt urgent referral to for further investigation. Nasal Obstruction Although highly subjective, nasal obstruction is a common medical complaint with multiple aetiologies within the paediatric population. Allergic rhinitis is a common cause and has significant impact on dentition, sleep and quality of life 12 . °ot only has it been associated with physical complications such as otitis media with effusions, asthma and °DB, but also mental complications such as sleep disturbances, poor school performance and hyperactivity 13 . Due to its influence on mouth breathing and adenoid hypertrophy, it is often linked with class malocclusion 14 . °eptal deviation whether congenital or acquired is another common cause. Diagnosisistypicallymadeonexamination with rhinoscopy or endoscopy. °reatment options for septal deviation often involve medical management of other causes of nasal obstruction, before consideration of surgical intervention often in the late teenage years. First line therapy for nasal obstruction often involves intranasal corticosteroids, regardless of specific underlying cause 8 . °hese medications are well tolerated and have favourable safety and efficacy profiles as discussed above. However, referral to an surgeon would allow for detailed assessment and for the development of an appropriate treatment regime based on the aetiology. Dentofacial abnormalities and the Role of the Dentist Although subject to much conjecture over the years, increasing evidence exist for the impact on nasopharyngeal airway obstruction on the development of dentofacial abnormalities. °sing computation fluid dynamics from cone-beam computated tomographic images, children with Class malocclusion have been demonstrated to have increased nasal obstruction, a finding °wasaki et al., 14 suggest may be due to inferior tongue posturing. Furthermore, increasing tonsillar size was associated with class malocclusion and anterior tongue posture. °n a recent systematic reviews by Becking et al., 3 the included studies con- sistently identified normalization of labial inclination in the upper and lower incisors towards a more horizontal mandibular growth pattern after adenotonsillectomy for obstruction. °ubsequent meta-analysis demonstrated significant horizontal catch- up growth of the mandible after adenoton- sillectomy. °hese findings suggest that relief of oropharyngeal obstruction may improve dentofacial outcomes. Furthering this idea, pre-pubertal children with obstructive mouth breathing who have not had adenotonsillectomy have been shown to have significantly increased palatal depth gains when compared to a cohort that underwent surgery at 1 year post-operatively (2.57% without vs 0.09% with adenotonsillectomy) 15 . Although small a percentage, 0.5mm arch change over 1 year may continue to accumulate without treatment of obstructive mouth breathing. °his has led Caixeta et al., to postulate that that without early intervention “the tendency is for the palate roof to deepened, whereas more normal growth pattern is established after tonsillectomy and adenoidectomy” 15 . °he size of tonsillar obstruction may also be an important factor, as more obstructive tonsils (grade 3 and 4) have been shown to be at increased risk of developing anterior open bite, likely due to the higher associations with mouth breathing 16 . °his anterior-open bite was able to be corrected in 77% of patients at 2 years after adenotonsillectomy in a study by Hultcrantz et al 17 . °uzzi et al., 18 have recently examined the orthodontic issues and therapeutic goals in the treatment of paediatric O°A, suggest the aim of orthodontic treatment in this population is to reduce the severity of O°A via “expansion of the upper jaw and/or mandibular advancement, thus increasing the airspace and improving airflow”. By enlarging the upper airways, Mandibular advancement devices (MAD) have been demonstrated to reduce AH° in the paediatric population 19 , however cannot normalize AH° values completely. °his reveals the importance of the dental practitioner in not only addressing the craniofacial sequela of disease, but also in addressing some of the symptoms of paediatric O°A. Assessment History and examination of the patient could include the following – mode of breathing (nasal/mouth), sleep related °lini°al Endoscopic view pre-tonsillectomy. Uvula is absent as it has been packed into the nasopharynx Nasendoscopic view of large adenoids obstructing the nasal passage TABLE 1 Brodsky Grading Scale adapted from (21) Grade° % of Oropharyngeal Airways ° 1° ≤ 25 ° 2° 26-50 ° 3° 51-75 ° 4° >75 TABLE 2: Indications for sleep study summarized from (24) u When clinical assessment suggested diagnosis of OSA u When clinical assessment suggests OSA and abbreviated testing is inconclusive u When severity of OSA is in doubt or there is significant risk of post-surgical complication (e.g., idiopathic thrombocytopenic purpura) u When clinical assessment suggested residual OSA following adenotonsillectomy or other treatment modalities u Where there is the presence of ongoing symptoms or other clinical features suggestive of persistent OSA, particularly those with: moderate-severe OSA preoperatively, obesity, craniofacial abnormalities that predispose to upper airway obstruction, neurological disorders and high risk congenital conditions (Down Syndrome, Prader-Willi Syndrome) u Abbreviated PSG testing may be indicated after assessment by paediatric sleep specialist