2. WHAT IS OBSTRUCTIVE SLEEP APNEA
(OSA)?
• Sleep disorder characterized by
recurrent episodes of narrowing or
collapse of pharyngeal airway during
sleep despite ongoing breathing
efforts.
• These often lead to
• Acute derangements in blood gas
disturbances
3. DEFINITIONS
• Apnea is cessation or near cessation of flow
(inspiratory flow decreases to < 20%) ≥ 10 seconds
• Hypopnea is continued breathing, but ventilation
decreases by 50% for ≥ 10 seconds
• Apnea-Hypopnea Index (AHI) – total number of
apneas and hypopneas per hour of sleep
4. SLEEP DISORDERED BREATHING
•Obstructive Sleep Apnea
•Central Sleep Apnea
• Cessation of ventilation during sleep due to loss of
ventilatory drive
• ≥ 10 second pauses with no associated respiratory
effort
15. SIGNIFICANCE OF OSA
•Loss of air to lungs may happen
many times per hour
•Blood oxygen drops below the
90% level causing the patient to
arouse to breath
•Arousal causes loss of sleep,
daytime sleepiness, decreased
production, increased accidents,
etc.
•May cause medical problems
ranging from mild to “life
threatening”
16. WHY DOES THIS MATTER?
• Excessive daytime drowsiness
• Impaired cognitive performance
• Poor quality of life
• Increased risk of MVA (Motor vehicle accidents)
• Adverse cardiovascular outcomes
• Pulmonary hypertension
18. OBESITY
•Alters upper airway mechanics during sleep
1.Increased parapharyngeal fat deposition:
neck circumference: > 17” males
> 16” females
With subsequent:
smaller upper airway
increase the collapsibility of the pharyngeal
airway
19. OBESITY
2. waist circumference
Fat deposition around the abdomen
produces
reduced lung volumes (functional
residual capacity) which can lead to
loss of caudal
traction on the upper airway
low lung volumes are associated with
diminished oxygen stores
20. RISK FACTOR: AGE
0
5
10
15
20
25
30
35
30-39 Yrs 40-49 Yrs 50-60 Yrs
Female
Male
% with
AHI > 5
Adapted from Young T et al.
N Engl J Med 1993;328.
2006 American Academy of Sleep medicine
25. MEDICAL RESPONSIBILITY
•Diagnosis and determine
presence and severity of an OSD
- “Sleep Study”
•Treatment
Dental Responsibility
z Recognize and refer
z Provide support when requested
27. DIAGNOSING SNORING / OSA
•Medical history
•Sleep history
•Extended dental examination
including TMJ evaluation
•Epworth Sleepiness Scale
•Preliminary diagnosis
•Referral for medical evaluation (sleep
study)
28. DIAGNOSIS:
• Nocturnal symptoms
1. Snoring
– reflects the critical narrowing
• - prevalence increases with age (60%, 40%)
- the most frequent symptom of OSA
29. DIAGNOSIS
(nocturnal symptoms continued)
2. Witnessed apneas
3. Nocturnal choking or gasping
- report of waking at night with a choking sensation;
passes within a few seconds
4. Insomnia
- sleep maintenance insomnia
- (few have difficulty initiating sleep)
30. CLINICAL FEATURES
• Daytime symptoms
1. Excessive daytime sleepiness
- severity can be assessed
subjectively = questionnaires
(Epworth Sleepiness Scale)
objectively
MSLT = Multiple Sleep Latency Test
MWT = Maintenance of wakefulness Test
Osler Test
32. EPWORTH SLEEPINESS SCALE
•Likeliness to doze off or fall asleep in
certain situations versus to just feeling
tired
•Use the following scale to choose the
most appropriate number for each
situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
33.
34. HOW MUCH AIR SPACE IS
PRESENT?
•Open fairly wide and slightly protrude
your tongue
•Grade - I, II, or III
(Jamieson AO, Becker PM. Snoring: its
evaluation and treatment. Hospital
Medicine. March 1996)
35. Grade I
The tonsillar pillars, soft palate, and uvula
can be seen, with at least 5 mm between the
tip of the uvula and the base of the tongue
36. Grade II
Tonsillar pillars and soft palate remain
visible, tip of the uvula is obscured by the
base of the tongue: part of the free edge of
the soft palate is still visible
39. DIAGNOSIS
• Combined assessment of clinical features and objective sleep
study data.
• The gold standard: overnight polysomnogram
• The Polysomnogram (PSG):
• Provides detailed information on sleep state and
respiratory and gas exchange abnormalities.
42. PSG
• Recurrent episodes of complete or partial collapse of
the upper airway are recorded as apnea or hypopnea
events.
Apnea = complete cessation of airflow
for at least 10 seconds
Hypopnea = 25 – 50% reduction in oronasal airflow
associated with desaturation or an arousal from sleep.
43. PSG
• Sleep apnea severity index:
• AHI = apnea-hypopnea index
= # of apneas and hypopneas / hour of sleep
• Mild: 5 – 15 events/hour of sleep
• Moderate: 15 – 30 event/hour of sleep
• Severe: > 30 events/hour of sleep
53. CPAP
• Indications
• Based on AHI
• CMS: AHI >15 events/h or with AHI 5-14 events/h with clinical
sequelae (excess daytime sleepiness, cognitive impairment, mood
DO, insomnia, cardiovascular dis.)
• Consider CPAP in patients with lower AHI (~5) who have symptoms,
perform mission critical work (pilots, bus drivers)
• Mechanism
• Splints open the upper airway to prevent airway collapse
54. CPAP
• Has been shown to objectively:
• Decrease MVA
• Decrease blood pressure
• Decrease day time sleepiness
57. SURGICAL MANAGEMENT
•Perioperative Issues
• High risk in patients with severe symptoms
• Associated conditions CVD
• Nasal CPAP often required after surgery
• Nasal CPAP before surgery improves postoperative
course
• Risk of pulmonary edema after relief of obstruction
58. SURGICAL MANAGEMENT
• Nasal Surgery
• Limited efficacy when used alone
• Verse et al 2002 showed 15.8% success rate when used
alone in patients with OSA and day-time nasal congestion
with snoring
• Adenoidectomy (children)
59. SURGICAL MANAGEMENT
•Uvulopalatopharyngoplasty
• The most commonly performed surgery
for OSA
• Levin and Becker (1994) up to 80% initial
success decreased to 46% success rate at
12 months
• Friedman et al showed a success rate of
80% at 6 months in carefully selected
patients
61. SURGICAL MANAGEMENT
•Tongue Base Procedures
• Lingual Tonsillectomy
• may be useful in patients with hypertrophy, but usually in
conjunction with other procedures
62. SURGICAL MANAGEMENT
•Tongue Base Procedures
• Lingualplasty
• Chabolle, et al success rate of
77% (RDI<20, 50% reduction)
in 22 patients in conjunction
with UPPP
• Complication rate of 25% -
bleeding, altered taste,
odynophagia, edema
66. SURGICAL MANAGEMENT
• Hyoid Myotomy and
Suspension
• Advances hyoid bone
anteriorly and inferiorly
• Advances epiglottis and
base of tongue
• Performed in conjunction
with other procedures
• Dysphagia may result
67. SURGICAL MANAGEMENT
• Maxillary-Mandibular Advancement
• Severe disease
• Midface, palate, and mandible advanced
anteriorly
• Limited by ability to stabilize the segments and
aesthetic facial changes
69. SURGICAL MANAGEMENT
• Surgical management provides effective management
for OSA
• Can be safely performed in most patients with proper
preoperative preparation
• Surgery should be considered for patients unable to
utilize nonsurgical management
71. TYPES OF DENTAL DEVICE DESIGNS
FDA has cleared the following types of devices under this
regulation:
• Tongue retaining devices
• Mandibular repositioning devices
• Palatal lifting devices
74. TREATMENT PROTOCOLS FOR UTILIZING OA
THERAPY
1. Assessment by a sleep physician:
2. The sleep physician provides the dentist
with a written referral as well as copy of
the diagnostic sleep study report.
75. TREATMENT PROTOCOLS FOR UTILIZING OA
THERAPY
3. The dentist assesses if the patient is a
candidate for OA therapy, and the patient
is advised of the appropriate OA design(s)
for that patient
4. An informed consent about the risks and
benefits of OA therapy for SRBD is obtained
76. TREATMENT PROTOCOLS FOR UTILIZING OA
THERAPY
5. OA therapy is initiated by the dentist
6. The patient is referred back to the sleep
physician for medical assessment by the
sleep physician relative to the OA’s therapy
effectiveness.
77. TREATMENT OBJECTIVES
•“For patients with primary snoring without
features of OSA or upper- airway resistance
syndrome, the treatment objective is to reduce
the snoring to a subjectively acceptable level.”
• “For patients with OSA, the desired outcome of
treatment includes the resolution of the clinical
signs and symptoms of OSA and the
normalization of the apnea-hypopnea index
81. COMPARISON OF OAS WITH CPAP
• CPAP was more efficacious in reducing the AHI to normal levels
as well as controlling snoring in almost all patients,
• OA demonstrated better compliance when compared to CPAP.
84. MECHANISM OF ACTION:
To prevent the tongue from
approaching the posterior wall of
the pharynx, the patient projects
the tip of the tongue into a hollow
bulb, thereby creating a suction
which retains the tongue in an
anterior position
85.
86. INDICATIONS FOR TRDS
• Edentulous patients
• Patients with potential temporomandibular joint
problems
Problems with TRDs
z Sore tongue
z taste alteration
97. DENTAL CONSIDERATION
• Adequate number of healthy teeth
• The patient should have the ability to protrude the mandible
forward and open the jaw widely without significant limitation
Contra indication
• “Moderate to severe TMJ problems
• “Significant bruxism
• Edentulous patients
98. Warnings
Use of device may cause:
• Tooth movement or changes in
dental occlusion
• Gingival or dental soreness
• Pain or soreness of the TMJ
• Obstruction of oral breathing
• Excessive salivation
99. PROBLEMS WITH MADS AFTER LONG
TERM USE (3 YEARS OR MORE)
•Minor jaw/facial, tooth, muscle pain
– 40%
•Xerstomia – 30%
•Very Satisfied – 82%
•Satisfied – 15%
•Painless but irreversible change in
occlusion - 26%
GT, Sohn JW, Hong CN. Treating obstructive sleep apnea
and snoring: assessment of an anterior mandibular
positioning device. J Am Dent Assoc. 2000;131:765-71.
102. INTER OCCLUSAL RECORD
• 1. Be able to maintain a lip seal with the OA seated on the
dentition, which will foster nasal breathing during sleep.
• 2. Provide the least amount of strain on the masticatory
musculature with the use of the OA.
• 3. Focus on the combined approach of mandibular
advancement and vertical opening: (a) for optimum
effectiveness of the OA
• (b) to lessen the possibility of occlusal changes with the use of
an OA.
103. INTER OCCLUSAL RECORD
• Vertical relation
• Start at between 5 and 7 mm interincisally (Edge to edge)
• Take into consideration Maintain a lip seal
104. INTER OCCLUSAL RECORD
• Horizontal relation
• Class I (full dentition) Incisors at edge to edge
Advanced 1–4 mm past edge to
edge
105. INTER OCCLUSAL RECORD
• Horizontal relation
• Class II division 1 to >5 mm overjet
• Class II division 2
Advanced up to 5 mm
Advance 2–4 mm beyond
edge to edge
106. INTER OCCLUSAL RECORD
• Horizontal relation
• Class III
• Pseudo class III
Minimal to no advancement
Focus on vertical
Minimal advancement (1–3 mm)
119. PATIENT INSTRUCTIONS FOR
ADJUSTMENT
(DEPENDS ON DEVICE BUT
TYPICAL):
•No adjust for first 3 nights to allow
patient to become accustom to
device
•Protrude device 0.25 mm per night
for 3 – 4 nights, stop, check for
improvement
•Continue until symptoms are
relieved or reduced or TMJ
symptoms develop
120. EVALUATION
•Following relief of symptoms allow
patient to wear device for 2 – 4
weeks
•Have patient wear a Pulse Oximetry
device and determine success of
treatment
•Continue adjustments and follow up
Pulse Oximetry
•Refer to Physician for reevaluation
(2nd polysomnography)
121. PATIENT SHOULD EXPECT
•Lips will be very dry - lip balm
•Difficulty going to sleep for a few
nights
•Lots of saliva - on pillow
•Teeth may become sensitive -
seek care immediately - usually
slight adjustment
122. PATIENT SHOULD EXPECT
•TMJ discomfort - May be sore for a
few minutes during early
adjustment, must be relieved by
moving mandible posteriorly
