ABDSM Board Review (from Quizlet) Flashcards
1
Q
Which of the following statements is true regarding a modified mallampati classification of the oral pharynx?
A. Mallampati II allows visualization of only the hard palate
B. Malampati III allows visualization of only the hard palate
C. Malampati classifications are taken with the patient sedated and reclined
D. Mallampati classifications of IV have greater odds ratio than Mallampati classifications of I for severe OSA
A
D. Mallampati classifications of IV have greater odds ratio than Mallampati classifications of I for severe OSA
2
Q
What 8 item questionnaire was developed to perioperatively screen for risk of OSA?
A. ESS
B. STOP-BANG
C. MSLT
D. Berlin
A
B. STOP-BANG
3
Q
In the pathophysiology of sleep apnea, airway patency and stability is promoted by which factor?
A. Increased lung volume
B. Shorter mandible
C. Increased parapharyngeal fat deposition
D. Negative inspiratory pressure
E. Reduced pharyngeal muscle dilator activity
A
A. Increased lung volume
4
Q
Oral appliance therapy commonly provides successful sole therapy for which of the following sleep-related breathing disorders?
A. Primary central sleep apnea B. Cheyne-Stoke periodic breathing C. Obesity hypoventilation D. Overlap syndrome (OSA and COPD) E. None of the above
A
E. None of the above
5
Q
Which of the following is true about OSA and HTN?
A. Ambulatory BP is increased in OSA patients primarily due to increased salt intake associated with elevated ghrelin levels
B. Ambulatory BP normally increases in the early AM before awakening - this increase is blunted in OSA
C. Untreated OSA is associated with a similar risk of HTN at all severity levels
D. The risk of HTN in untreated OSA is due to intermittent hypoxia, sympathetic overactivation, inflammation, and other complex factors
A
D. The risk of HTN in untreated OSA is due to intermittent hypoxia, sympathetic overactivation, inflammation, and other complex factors
6
Q
Across a general population, what is the most common sleep disorder?
A. RLS B. Narcolepsy C. Delayed sleep phase syndrome D. Insomnia E. Obstructive sleep apnea
A
D. Insomnia
7
Q
Measurement has shown that patients with sleep apnea have smaller upper airways than those without sleep apnea but manage to keep an open airway during wakefulness by:
A. Mouth Breathing
B. Increased muscle tone on inspiration
C. Increased blood flow to the soft tissue
D. Frequent bruxing
A
B. Increased muscle tone on inspiration
8
Q
Key features of sleep apnea as recorded during an in-lab sleep study include marked reduction or absence of air flow, arousals from sleep, slowing of heart rate and:
A. Choking or gasping for air B. Oxygen desaturation C. Flattening of the nasal pressure signal D. Flailing of the arms and legs E. Sawtooth waves in the EEG
A
B. Oxygen Desaturation
9
Q
Who publishes the CPT codebook?
A. The Centers for Medicare and Medicaid Services
B. The American Medical Association
C. The Office of the Inspector General
D. The Durable Medical Equipment Service
E. The American Academy of Sleep Medicine
A
B. The American Medical Association
10
Q
A 48 year old man is treated with OAT for his moderate OSA. On repeat sleep testing, his apnea-hypopnea index (AHI) has decreased to 3 events per hour, and he reports resolution of snoring and daytime sleepiness. What is the most reasonable dental-medical sleep medicine follow up regimen for this patient?
A. As needed
B. Every 6 months for the first year, then annually
C. Monthly for the first 6 months, then every 6 months
D. Every other year
A
B. Every 6 months for the first year, then annually
11
Q
Which of the following would exclude oral appliance therapy as a first treatment trial for OSA?
A. Xerostomia
B. Edentulism
C. Micrognathia
D. Steep mandibular plane angle
A
B. Edentulism
12
Q
Reviewing your patient’s diagnostic polysomnogram, you note more than a 50% epoch consists of alpha waves. According to the current PSG scoring guidelines, the patient is in which stage of sleep?
A. Stage I NREM
B. Stage II NREM
C. Stage III NREM
D. Stage REM
A
A. Stage I NREM
13
Q
A patient presents for an evaluation to determine their candidacy for an oral appliance to treat their mild OSA. During your examination, you note the presence of TMD. This might include the following:
A. Pain in the TMJ
B. Pain in the muscles of mastication
C. Anomalies in mandibular movement
D. All of the above
A
D. All of the above
14
Q
The qualified dentist designation (QDD) came about in response to the 2015 practice guidelines paper recommending that physicians refer patients to dentists “qualified” to treat sleep related breathing disorders. This was based upon recognition of which of the following?
A. Older dentists have more experience than younger dentists
B. All dentists have the skills they need to deliver knowledgeable care
C. Oral appliance efficacy data collected in studies is obtained by dentist with extensive clinical experience
D. Training in dental schools on oral appliance therapy has become common place
A
C. Oral appliance efficacy data collected in studies is obtained by dentist with extensive clinical experience
15
Q
The 2015 Practice Guidelines created through cooperative effort of the AASM and AADSM suggest a physician should seek collaboration with a qualified dentist, described as someone who has at least:
A. Board certification
B. Facility accreditation
C. Completion of a 1 yr residency in dental sleep medicine
D. Additional training or experience in dental sleep medicine
A
D. Additional training or experience in dental sleep medicine
16
Q
An understanding of loop gain is important to the clinical practice of dental sleep medicine because:
A. It excludes the possibility of cheyne stokes breathing in patients with severe OSA
B. It is the basis of the Mallampati classification system
C. It defines the number of sequential obstructive apneas in an epoch
D. It contributes to the multifactorial nature of sleep related breathing disorders
A
D. It contributes to the multifactorial nature of sleep related breathing disorders
17
Q
With regards to biomechanical properties of the upper airway, which statement is true?
A. Sleep apnea patients paralyzed during general anesthesia (neural drive removed) demonstrated airway compliance similar to healthy subjects
B. Sleep apnea patients had more negative closing pressures
C. Sleep apnea patients demonstrate a more positive Pcrit
D. There is no correlation between collapsibility when awake and collapsibility when asleep
A
C. Sleep apnea patients demonstrate a more positive Pcrit
18
Q
Tagged MRI recently showed 3 patterns of tissue formation during mandibular advancement. Which of these was NOT observed?
A. The whole tongue moved forward “en bloc”
B. Only the superior posterior portion of the tongue moved forward
C. The posterior tongue did not move, but the whole tongue elongated
D. Only the inferior posterior portion of the tongue moved forward
A
B. Only the superior posterior portion of the tongue moved forward
19
Q
In Van Heasendonck’s 2015 systematic review of oral appliance health benefits, mean disease alleviation was calculated using the following:
A. An embedded microsensor
B. A highly compliant patient population
C. Patient’s diaries of hours of nightly device use
D. Patient’s attestations to hours of nightly device use
A
A. An embedded microsensor
20
Q
Caffeine promotes wakefulness by suppressing or blocking:
A. Thyroid stimulating hormone
B. Growth hormone
C. Orexin
D. Adenosine
A
D. Adenosine
21
Q
A study design where one or more population samples are followed prospectively to determine which participant’s exposure characteristics (risk factors) are associated with a disease or outcome is called a:
A. Randomized control trial
B. Non-randomized control trial
C. Cohort study
D. Case control study
A
C. Cohort study
22
Q
In an experiment where participants are randomly assigned, one group receives the drug or procedure, a placebo group’s treatment is disguised to resemble the drug or procedure being investigated and a control group receives nothing. Members of each group are prevented from knowing whether they are receiving active therapy. This would be called a:
A. Randomized control trial
B. Cohort study
C. Randomized case report
D. Blinded triple trial
A
A. Randomized control trial
23
Q
The masseter muscle originates at:
A. The temporal fossa
B. The zygomatic arch
C. The mylohyoid ridge
D. The coronoid process
A
B. The zygomatic arch
24
Q
In Sheats et. al., a morning occlusal guide is a common side effect management modality. Which of the following is CORRECT?
A. A MOG encompasses many custom made appliances and pre-fabricated devices used in an effort to reposition the mandible into its habitual pre-treatment position
B. A MOG has a very specific design as established by the AADSM consensus committee on side effects
C. A morning occlusal guide was shown to stretch the lateral pterygoid muscle to full functional length with EMG studies
D. Use of an MOG assures the patient that there will be no bite changes as a result of use of an oral appliance
A
A. A MOG encompasses many custom made appliances and pre-fabricated devices used in an effort to reposition the mandible into its habitual pre-treatment position
25
All of the following exacerbate sleep disordered breathing, EXCEPT:
A. Use of stimulants within 1 hr of bedtime
B. Consumption of a heavy meal within 1 hr of bedtime
C. Use of melatonin within 1 hr of sleep onset
D. Use of alcohol, especially as a means to induce sleep
C. Use of melatonin within 1 hr of sleep onset
26
A patient presents to consult with you regarding oral appliance therapy for their moderate OSA. They report intermittent "jaw pain" for the past 6 weeks. You should explain that:
A. It is best to postpone treatment until the pain has resolved
B. An oral appliance is contraindicated for a patient that has active TMD
C. A comprehensive oral-facial evaluation is necessary to ID the source of their jaw pain before considering or proceeding with oral appliance therapy
D. An oral appliance will improve their jaw pain if the source of the pain is muscular, and not originating from the TMJ
C. A comprehensive oral-facial evaluation is necessary to ID the source of their jaw pain before considering or proceeding with oral appliance therapy
27
The most recent research points to the primary etiology of sleep bruxism as:
A. Nicotine, ethanol, recreational drug or caffeine use
B. Peripheral triggers such as occlusal discrepancies
C. Central factors such as stress and psychosocial influences
D. The result of a combination of environmental, biological, and psycho-social influences
D. The result of a combination of environmental, biological, and psycho-social influences
28
According to Caples, et al, risk of fatal and non-fatal cardiovascular events is significantly increased in patients with:
A. Mild OSA
B. Severe OSA
C. Severe OSA on CPAP therapy
D. Both A and B
B. Severe OSA
29
In sleep, heart rate...
Slows 10-15 BPM
30
In sleep, breathing...
slows
31
In sleep, muscles
relax
32
In sleep, BP
Decreases (morning dip)
33
In sleep, body temperature...
Decreases, then begins to rise just before morning wakeup time
34
Which neurons are sleep promoting?
- Ventrolateral Preoptic System (VLPO)
| - Median Preoptic Nuclei (MNPO)
35
Loss of which neurons promotes profound insomnia and sleep fragmentation?
VLPO
36
What does the flip flop switch refer to?
Mutual inhibition of sleep and wake promoting neurons triggered by changes in drive for sleep or circadian altering signal
37
When do the deepest stages of sleep occur?
20 minutes after sleep onset
38
What is referred to as the circadian pacemaker?
SCN (Suprachiasmatic nuclei of anterior hypothalamus)
39
What does the SCN promote?
Wakefulness, and maintains sleep after sleep drive dissipates in the 2nd half of the night
40
Where is melatonin released?
Pineal gland
Regulated by SCN
41
Is melatonin necessary for sleep?
No, but helps synchronize circadian rhythms
42
What causes sleep drive to buildup throughout the day?
Buildup of adenosine
Induces sleep by inhibiting wake promoting neurons
43
What neurotransmitter does caffeine inhibit?
Adenosine
Promotes wakefulness
44
What are some characteristics of REM?
- Increased brain wave activity
- Eyes move back and forth rapidly
- Atonic muscles
- Dreaming
- High cholinergic, low adrenergic state
45
When is REM more prominent?
Second half of the night - and episodes lengthen throughout the night
46
What % REM do premature infants have?
80%
47
What % REM do full term neonates have?
50%
48
What % REM do adults 20-69 have?
25%
49
How much sleep does N1 encompass?
5-10%
Very light sleep
50
How much sleep does N2/N3 encompass?
65-70%
51
What phase of sleep are sleep spindles present in?
Mostly N2
Very small amount present in N3
52
Where do sleep spindles originate?
Thalamus
53
Where do sleep spindles propagate?
Cortex
54
What are sleep spindles associated with?
Offline memory processes
**Get increased spindle activity after learning
55
What waves are associated with N1 sleep?
Vertex sharp waves - alpha waves
56
What sleep study architecture is associated with N2 sleep?
- K complexes
| - Sleep spindles
57
When do REM stages start?
80-100 minutes after onset of sleep
58
How long are the cycles between REM and NREM?
90 minutes
59
What are the main purposes of sleep?
- Enhance memory consolidation
- Promote alertness
- Hormone release (ADH, GH, Oxytocin, Prolactin)
- Clear metabolites from brain
60
How much does brain energy metabolism decrease by during sleep?
25%
61
What hormones are released during sleep?
- GH
- ADH
- Oxytocin
- Prolactin
62
What does the glymphatic system do?
Flushes out toxins, proteins, metabolic waste from the brain
63
How is the sleep cycle in a newborn different?
- Enter REM before NREM
- Shorter sleep cycles (50 min as opposed to 90 min)
- 50% REM (declines over first 2 yrs to 20-25%)
- No Slow Wave Sleep (N3)
64
What phase of sleep does slow wave sleep occur in?
N3
65
How does slow wave sleep change over time?
- Not present at birth
- Emerges in first 2 years
- Decreases during adolescence by 40% in preteen years
66
How is N3 sleep different between men and women?
Women have a higher % of N3 sleep than men, and it decreases slower throughout life
67
Where are central chemoreceptors located?
Ventral Medulla on brain
68
What do central chemoreceptors detect?
- CO2
| - H+
69
Where are peripheral chemoreceptors located?
Carotid Body
70
What are peripheral chemoreceptors sensitive to?
- HYPOXIA
| - Also detect changes in CO2, pH, temperature
71
What mainly controls alveolar ventilation?
Arterial CO2
Have a linear relationship of minute ventilation as CO2 increases
72
How does O2 relate to ventilation drive?
Minimum O2 ventilation drive until PO2 <60, then get enhanced ventilation
73
How does CO2 relate to ventilation drive?
Linear relationship - minute ventilation increases as CO2 increases
74
What is the definition of apnea?
Cessation of airflow for 10 seconds or longer
75
What is the definition of hypopnea?
Decrease in airflow lasting for 10+ seconds
30% reduction of airflow
AND
At least a 3% oxygen desaturation OR an arousal (CMS says 4%)
Shallow breathing
Decreased minute ventilation
76
Why do humans have sleep apnea and others do not?
Longer, more collapsible airway. No overlap of epiglottis and soft palate
Allows advanced speech but unprotected airway during sleep
77
What is the measure of airway patency?
Pcrit
Determined by sum of structural and neuromuscular determinants of airway collapsibility
78
What does more negative Pcrit mean?
Airway is open
Pcrit
79
What are the 2 fundamental sleep induced changes in OSA?
- Changes in passive mechanics of upper airway
| - Critical reliance on chemosensitivity for control of respiratory motor output and its stability
80
Where does the obstruction most often occur in OSA?
Soft palate (81%)
81
Where else can the obstruction occur in OSA?
- Tongue base (46.6%)
- Hypopharyngeal collapse (38.7%)
- Multilevel collapse - most common is palate and tongue base
82
How many adults have mild OSA?
1/5
83
How many adults have moderate-severe OSA?
1/15
84
What are some risk factors for OSA?
- Obesity
- Male
- Diabetes
- HTN
- Postmenopausal
- Large neck >16 inches
- Atrial fibrillation
- African american, asian, hispanic
- Frequent nocturia
- Upper airway anatomic obstruction
85
What is a normal score on the ESS?
<10
86
What are some diurnal symptoms of OSA?
- Daytime sleepiness
- Memory and concentration dysfunction
- GERD
- Irritability, depression
- Traffic accidents
- Waking with a dry mouth, irritated throat
87
What are some nocturnal symptoms of OSA?
- Heavy, persistent snoring
- Apnea with limb movement
- Nocturia
- Nocturnal sweating
- Sudden awakening with noisy breathing
- Accidents related to sleepiness
- Insomnia
88
What does AHI consist of?
Apneas + Hypopneas / time
89
What is the difference in AHI and RDI?
RERAs are included for RDI
CMS views AHI = RDI because they don't recognize RERA's
90
What is considered mild OSA?
5-15 RDI per hour
CMS will cover OSA therapy if comorbidity like:
- HTN
- Stroke
- Sleepiness
- Ischemic heart disease
- Insomnia
- Mood disorders
91
What is considered moderate OSA?
15-30 RDI per hr
92
What is considered severe OSA?
30+ RDI per hr
93
What is ODI?
Oxygen desaturation index
of 3% desaturations per hr
94
What does a CPAP do?
- Splints airway open
- + pressure decreases fluid leakage into alveoli
- + pressure decreases work of breathing and O2 requirements
- Improves cardiac function and output by decreasing preload and afterload
- Increases lung volume
95
Does CPAP prevent CV disease in patients with CVD + OSA?
No - not compared to usual care alone
96
What is the compliance rate for CPAP?
30-70%
97
Is nasal patency a major contributor to OSA?
NO - using nasal dilators doesn't significantly improve nasal flow or apnea index
98
What are the 3 patterns of tissue deformation during mandibular advancement?
- Whole tongue moves forward en bloc
- Whole tongue elongates
- Inferior tongue moves forward
**POSTERIOR TONGUE DOESN'T MOVE
99
What are the cardiovascular benefits of oral appliance therapy?
- Reduced BP (34-75%)
| - Endotheilal and left ventricular function improves
100
Does bariatric surgery/weight loss cure OSA?
No - most patients will still have moderate residual OSA - still needs treatment
Does reduce AHI though
101
How are apneas scored? What are the requirements?
Decreased flow signal >90% for >10 seconds
BOTH must be met
102
What is the difference between obstructive and central apnea?
Obstructive has continued effort, central has no effort
Mixed = absence of effort initially followed by resumption of effort
103
What are the requirements for a hypopnea?
- Decreased flow >30% of baseline for >10 seconds
- A 3% oxygen desaturation from baseline OR an arousal
**CMS requires 4%
104
When is a hypopnea considered obstructive?
If any of the following occur:
- Snoring
- Inspiratory flattening
- Thoracoabdominal paradox
105
What is a RERA?
Breathes >10 seconds by increasing rate or flattening, leading to an arousal when it doesn't meet criteria for apnea or hypopnea
106
When MUST you do a PSG over HST?
- Cardiorespiratory disease
- Neuromuscular weakness
- Hypoventilation
- Opiate use
- Hx of stroke
- Severe insomnia
107
What are the 3 primary signals tested with hST?
- Airflow
- Respiratory effort
- Oximetry
108
Do HST's over or underestimate OSA severity?
Overestimate
109
What do HST's not measure?
Total sleep time, RERA's
110
How is sleep monitored with HST?
SCOPER
- Sleep
- Cardiac measure
- Oximetry
- Position
- Effort
- Respiration
111
How does OSA(OAT???) treat SDB?
- Maintains mandible closed
- Increases anterior and lateral dimensions of oropharynx
- Increases anterior and lateral dimensions of velopharynx
- Increases base of tongue muscle tone
112
What are some observed changes with OAT?
- Increased lower face height
- Lateral displacement of parapharyngeal fat pads
- Anterior positioning of base of tongue
- Increase in total airway volume
113
What are some craniofacial characteristics that lead to increased risk of OSA?
- Reduced mandibular body length
- Inferiorly positioned hyoid bone
- Retroposition of maxilla
- Airway length
114
What % of patients use CPAP >4 hrs per night after 6 months?
50%
115
What reduces AHI more, CPAP or OAT?
CPAP
116
Does OAT reduce BP?
Data is limited, but in some patient populations, it is as effective as CPAP at reducing BP
117
What factors are equal between OAT and CPAP?
- Quality of life
- Effect on BP, endothelial function
- Cognitive performance
- Daytime sleepiness
- Reduction in arousal index
- Increased oxygen saturation
118
What are the main side effects of CPAP?
Irritated nose and mouth
119
When might a tongue retaining device be helpful?
- Ortho
- Edentulous
- Pts with TMD who can't tolerate an MAD
120
What are the requirements of an oral appliance?
- Allows advancements of 1mm or less
- Protrusive range of 5+mm
- Can be placed by patient or caregiver
- Maintains stable relationship to teeth, implants, or edentulous ridge
- Maintains structural integrity for a minimum of 3 years
121
How does protrusion alter the architecture of the airway?
- Displaces the suprahyoid and genioglossus muscle
- Advances and moves the mandible downward - increases tension on palatoglossal and palatopharyngeal muscles of the soft palate to maintain space in velopharynx
- Hyoid and mandible are held forward preventing backward rotation of mandible and posterior displacement of tongue into airway
- Lateral walls move laterally along the pterygomandibular raphe
122
What are the indications for MADs?
- Minimum of 10 sound teeth per jaw
- <20% tooth height destroyed by bruxism
- Ability to protrude the jaw 5-8 mm min
- Minimum maximum opening of 25-40 mm
123
What are some contraindications for MAD's?
- Protrusion of mandible <5mm
- Active severe TMD
- Painful opening or chewing
- Painful TMJ noise/locking
- Insufficient tooth support for the device
- PDD or tooth mobility
124
What is the single most important modifiable cause of sleep disordered breathing?
Weight gain
125
What stages of sleep is sleep bruxism most common in?
NREM 1 and 2 (mostly 2)
126
Where in the TMJ does rotation occur?
Lower compartment - first 20 mm of opening
Translation occurs in the upper compartment
127
Describe the articular disc
- Extension of fibrous capsule
- No innervation or blood supply
- Biconcave (like a bowtie)
128
Where does the anterior portion of the articular disc connect?
Superior head of lateral pterygoid
129
Where does the posterior portion of the articular disc connect?
Turns into highly innervated retrodiscal tissue
130
How is the articular disc held to the condyle?
Medial and lateral collateral ligaments
131
What nerve innervates the TMJ?
Mandibular division of the trigeminal
- Auriculotemporal
- Deep temporal
- Masseteric
132
What's the origin and insertion of the masseter?
Origin: Zygomatic arch
Insertion: Angle, Ramus
133
What nerve innervates the masseter?
Masseteric nerve (V3)
134
What is the action of the masseter?
Elevates mandible
135
What's the origin and insertion of the temporalis?
Origin: Temporal fossa
Insertion: Coronoid process of mandible
136
What nerve innervates the temporalis?
Temporalis nerve
137
What are the actions of the temporalis?
Elevates and retrudes the mandible
138
What's does the inferior belly of the lateral pterygoid do?
Depresses the mandible
139
What does the superior portion of the lateral pterygoid do?
Maintains articular disc position during rest and movement
140
What's the origin and insertion of the medial pterygoid?
Origin: Medial surface of lateral pterygoid plate
Insertion: Medial surface of mandible
141
What does the medial pterygoid do?
Protrudes and elevates the mandible
142
What are the signs/symptoms of synovitis?
- History of trauma
- Continuous TMJ pain
- Tender to palpation
- NORMAL ROM
- Acute malocclusion on injured side
**PAIN WITH CLENCHING, BUT NOT WHEN CLENCHING ON TONGUE DEPRESSOR
143
What's the treatment for synovitis?
- Anti-inflammatories
- Physical therapy
- Aqualizer or soft splint
- Hard splint if necessary
- Iontophoresis
- Phonophoresis
144
What are the characteristics of temporal tendonitis?
- Pain at temporalis insertion
- Possible joint, ear, cheekbone, molar pain
- Could feel like a migraine and cause limited opening
145
What's the treatment for temporal tendonitis?
- Injection insertion
| - Physical therapy
146
What are the characteristics of a non-reducing disc displacement?
- Maximum opening 26 mm
- Deflection TO affected side
- No clicking
- History of locking
- History of reducing disc displacement
147
How do you diagnose a non-reducing disc displacement?
MRI with closed and wide open views
148
What is the difference between deviation and deflection?
Deviation: Jaw goes to the side as you open then recenters at maximum opening
Deflection: Jaw opens and stays off to one side at maximum opening
149
What is normally the reason for pain in the TMJ after OAT?
Too much/little protrusion
150
What is normally the reason for pain in the masseter after OAT?
Usually due to too much vertical, lack of posterior support, or uneven posterior support
151
How does a case control study work?
Those with disease get matched with those without disease
Look back in time for an exposure
152
What is a cohort study?
No disease present to start
Each group exposed to different factors - determine which group has more disease over time
153
What does the P value measure?
Statistical significance - NOT clinical significance
So shows there is a difference in effect between two things, but not the number needed to treat or the magnitude of the effect
154
What P value shows something is due to chance?
P > 5%
155
Which is more effective at managing mild to moderate OSA with a MAD, 50% or 75% protrusion?
Either - they are equal
For severe OSA, 75% protrusion is slightly more effective
156
What do you do at the 1 month post-delivery appointment?
- Non diagnostic HST
- Nocturnal pulse oximetry
- After protrusive position, send for PSG or diagnostic HST
157
What are some benefits of combination CPAP and MAD therapy?
- Can reduce CPAP pressure
- Reduced leakage
- Less cumbersome mask interface (no straps)
- Improved compliance and efficacy
158
What is the difference between type 1 and type 2 combination therapy?
Type 2 is connected, type 1 is not connected
159
How does MAD work on patients with positional OSA?
MORE EFFECTIVE
160
Is MAD treatment more effective with patients with a higher BMI or lower BMI?
Lower
161
How does nasal obstruction relate to SDB?
Associated with mouth breathing which can decrease effectiveness of OAT
Higher airway resistance is associated with a poorer response to OAT and requirement for higher pressures with PAP
162
What is nasal obstruction an independent risk factor for?
- Habitual snoring
- Non restorative sleep
- Daytime sleepiness
163
What is increased nasal resistance an independent risk factor for?
- OSA CPAP tolerance
| - Oral appliance failure
164
What is orofacial myofunctional therapy?
Neuromuscular re-education of the orofacial muscles with exercises
165
What does Orofacial Myofunctional Therapy DO?
- Eliminates oral habits (i.e. nail biting)
- Improves static and dynamic tongue position
- Improves lip seal
- Enhances nasal breathing
- Promotes proper chewing, swallowing
166
During the narrative history, it is not entirely clear what Larry would describe as his chief complaint. If a dental sleep medicine clinical fails to determine a patient's chief complaint or complaints:
a. The SOAP note is invalid and cannot be used for insurance submission
b. The DSM provider will not know when to stop advancing the device
c. The DSM provider may not know how to motivate the patient to remain compliant with treatment during the acclimation period
d. The DSM will never make the patient happy
c. The DSM provider may not know how to motivate the patient to remain compliant with treatment during the acclimation period
167
In addition to being able to wear his oral appliance comfortably all night and based upon the narrative, what other reasonable goals of treatment should the dentist discuss with Larry and record in the plan?
a. patient is able to sleep with his spouse without disrupting her sleep. Awakens refreshed without feeling a need for napping and all apneas are eliminated without further need for CPAP
b. Patient is able to sleep with his spouse without disrupting her sleep, is able to wear his CPAP in combination with his OA for at least a portion if not all night, awakens more refreshed, and continues to see progress in weight loss
c. Patient is able to sleep with his spouse without disrupting her sleep, is able to sleep through the night, awakens more refreshed, and is able to lose 50 lbs in 3 months
d. Patient continues to sleep separately from his spouse so that if he has persistent snoring or apneas it does not bother her sleep
b. Patient is able to sleep with his spouse without disrupting her sleep, is able to wear his CPAP in combination with his OA for at least a portion if not all night, awakens more refreshed, and continues to see progress in weight loss
168
What are the 3 key parts of informed consent that were discussed during the patient consultation?
a. The risks of sleep apnea with no treatment, the risks of treatment with OA, and the alternative therapies to OA
b. The risks of sleep apnea with no treatment, the risks of treatment with OA, and a referral for bariatric surgery
c. The risks of continued CPAP use, the risks of treatment with OA, and the risks of no treatment
d. Informed consent for OAT should only address possible consequences of OA use
a. The risks of sleep apnea with no treatment, the risks of treatment with OA, and the alternative therapies to OA
169
Larry reports that he often falls asleep when he is watching TV in the middle of the day and sitting in his recliner. This should be recorded in the following part of his clinical note:
a. Subjective
b. Objective
c. Assessment
d. Plan
a. Subjective
170
Larry has not been successful in wearing his prescribed CPAP more than a few hours per night on average. This should be recorded in the following part of his clinical note:
a. Subjective: Review of Systems
b. Objective: HPI
c. Assessment
d. Subjective: HPI
d. Subjective: HPI
171
"CPAP intolerant patient with severe OSA is a candidate for trial of OAT with expectation of less than complete disease eradication from OAT alone" would best fit in this category of the SOAP note.
a. Subjective
b. Objective
c. Assessment
d. Plan
c. Assessment
172
At the end of your discussion with Larry, you inform him that you will be contacting his sleep physician to report on the goals of therapy for the patient and Larry's stated desire to move forward with OAT. Another critical purpose for contacting the diagnosing physician is to:
a. Request contact information for a bariatric specialist so Larry can pursue surgery in combination with his trial of OAT
b. Arrange a lunch meeting so you can encourage the physician to start referring all mild and moderate sleep apnea patients for a trial of OAT before any CPAP trial
c. Request a prescription and/or letter of medical necessity for OAT
d. Impress the physician with your knowledge of PSG
c. Request a prescription and/or letter of medical necessity for OAT
173
During your sleep interview with Larry, you discover that he is generally able to fall asleep with his CPAP on, but cannot sleep more than 3 hours with it in place. Which of the following is the most likely explanation?
a. The CPAP ramp feature that starts the pressure low when first turned on and slowly increases to therapeutic levels, reaches its maximum at about 3 hours of continual use
b. His melatonin levels increase the longer he sleeps
c. He is more motivated to wear it at the beginning of the night since his wife is also trying to fall asleep
d. He has more sleep drive at the beginning of the night
d. He has more sleep drive at the beginning of the night
174
Which of the following is not an objective finding?
a. CPAP intolerance
b. BMI 35
c. 5mm overbite
d. Anterior incisal wear
a. CPAP intolerance
175
Which of the following is NOT an assessment?
a. Evidence of bruxism
b. Supine exacerbation of OSA
c. Weight: 270 lbs
d. Acceptable sleep hygiene practices
c. Weight: 270 lbs
176
Which of these is NOT an input component to the Circadian System?
A. Social Factors
B. Light
C: Superchiasmatic Nucleus
D. Alcohol
C: Superchiasmatic Nucleus
177
Which of the following will most likely contribute to phase delay?
A. Early Morning walk in sunshine
B. Blue screen use after 7PM
C. Morning use of 10,000 lux light box
D. Menopausal hormone changes
B. Blue screen use after 7PM
178
Which is true about influences on the sleep-wake cycle?
A. Caffeine promotes wakefulness by blocking Adenosine
B. Zeitgebers inhibit maintenance of a 24 hour cycle
C. Melatonin levels begin to decrease at sleep onset
D. The homeostatic drive decreases throughout the day
A. Caffeine promotes wakefulness by blocking Adenosine
179
Which of the following is true about sleep spindles?
A. They signal a movement of memory related data from the hippocampus to the cortex
B. They are most abundant in NREM I
They allow environmental input into the sleeping brain, such as bedroom noise
D. Men have twice as many sleep spindles as women
A. They signal a movement of memory related data from the hippocampus to the cortex
**Associated with OFFLINE MEMORY PROCESSES
180
Which PAP failure patient may benefit from combination PAP-MAD Therapy?
A. Pressure setting uncomfortably high
B. Unconscious removal
C. Claustrophobia
D. Mask causing facial sweating
A. Pressure setting uncomfortably high
181
What can be said regarding the standard of care for oral appliance titration or calibration procedures?
A. There is no standard titration procedure
B. Dentists or their supervised staff should titrate the devices for patients during clinic visits
C. Titration or calibration should proceed protrusively to the patient's maximum comfortable position
D. Titration or calibration should be routinely evaluated with home sleep testing
A. There is no standard titration procedure
182
Which of the following is true regarding Muller's maneuver?
A. It is used to distinguish between OSA and CSA
B. After forced expiration, an attempt at inspiration is made with closed nose and mouth
C. After maximum inspiration, an attempt at expiration is made with closed mouth and nose
D. It helps to clear the eustachian tubes during dramatic altitude changes
B. After forced expiration, an attempt at inspiration is made with closed nose and mouth
183
Which of the following would be difficult to ID during a nasal examination performed without an endoscope?
A. Deviated septal cartilage
B. Enlarged turbinates
C. Nasal valve collapse
D. Nasal polyps
D. Nasal polyps
184
What can be concluded regarding nasal obstruction and OSA?
A. Nasal obstruction is associated with snoring
B. Nasal obstruction is associated with OSA
C. Nasal obstruction is associated with lowered concentration of pulmonary nitric oxide
D. All of the above
D. All of the above
185
What can be concluded regarding nasal resistance and treatment of OSA with OAT?
A. Lower nasal resistance is a predictor of improved OAT response
B. Higher nasal resistance is a predictor of improved OAT response
C. Women with higher nasal resistance show improved response to OAT
D. Nasal resistance increases with protrusive positioning of the mandible
A. Lower nasal resistance is a predictor of improved OAT response
186
Where is the velo-pharynx?
A. In the nasopharynx above the horizontal position of the soft palate
B. In the oral pharynx behind the vertical portion of the soft palate
C. In the hypopharynx below the epiglottis
D. Between the velum and hard palate
B. In the oral pharynx behind the vertical portion of the soft palate
187
During a DISE procedure, the collapse of the velopharynx is described as "concentric". What is the best conclusion affecting treatment decisions?
A. Patient is a good candidate for hypoglossal nerve stimulation therapy
B. Patient is a good candidate for Oral Appliance Therapy
C. Patient is a good candidate for Pillar's Procedure
D. Patient is a good candidate for CPAP therapy
D. Patient is a good candidate for CPAP therapy
188
Which statement is true regarding the relationship between nasal obstruction and CPAP use?
A. Less than 20% of patients who try CPAP have nasal complaints
B. Nasal surgeries can decrease CPAP pressures
C. Nasal surgeries are not shown to improve CPAP compliance
D. Nasal surgeries increase ESS and AHI
B. Nasal surgeries can decrease CPAP pressures
189
What can be said regarding response rates to UTPP surgery based on the level of obstruction?
A. With obstruction at the oropharyngeal level, UPPP improved the apnea index the least
B. With obstruction at the nasal valve, UPPP improved the apnea index the most
C. With the obstruction at the oropharyngeal level, UPPP improved the apnea index the most
D. With obstruction at the hypopharyngeal level, UPPP improved the apnea index 87%
C. With the obstruction at the oropharyngeal level, UPPP improved the apnea index the most
190
Which is one of the inclusion criteria for a Hypoglossal nerve stimulation surgery?
A. AHI <15
B. BMI >32
C. Concentric collapse demonstrated with DISE
D. <25% central or mixed apneas
D. <25% central or mixed apneas
191
What does the "flip flop switch" describe?
Mechanisms in the control of the switch between REM and NREM, as well as Sleep and Wake
192
Where is the circadian clock in mammals?
SCN
193
How do we know that the sleep/wake cycle is regulated by the SCN?
Because even without environmental time cues, cycle continues on approximately a 24 hr basis
194
How does light get to the SCN?
Retinal ganglion cells
195
Where are sleep spindles present?
N2 mostly
Also N3
196
Where do sleep spindles originate?
Thalamus
197
Where do sleep spindles propogate?
Cortex
198
What are some characteristics of REM?
- Diffuse muscle atonia
- Vulnerable to enemies
- High cholinergic, low adrenergic state
- Consolidates emotional memories, reduces their emotional tone
199
What are sleep spindles associated with (what do they do)?
Offline memory processes
200
How much sleep does the AASM say adults 18-60 years of age require?
7+ hours
201
How much sleep does the NSF say that adults 26-64 should have?
7-9 hours
202
What % of the US population sleeps less than 7-8 hours?
35-50%
203
What % of the adult US population sleeps less than 6 hours?
15%
204
What is one night of sleep deprivation equal to?
Legal intoxication
205
What are the effects of sleep loss on the cardiovascular system?
- Increased heart disease
- Increased BP
- Increased risk for heart attack, stroke
IF <5 hrs of sleep, have 45% greater risk
206
What are the endocrine effects of sleep loss?
- Increase in stress hormones
- Affects thyroid, GH
- Diabetes and impaired glucose tolerance
- Affects appetite regulating hormone
207
What are the effects of sleep loss on the nervous system?
- Affects balance (more falls)
| - Increased tremors, seizures, pain, headaches
208
What are the effects of sleep loss on mental health?
- Decreased neurotransmitters affecting mood (stress, irritability, depression, alcohol use, suicide)
- Decreased quality of life
209
What are the effects of sleep loss on risk of early death?
Increases risk of dying by ANY cause by 15-30%
210
What are the characteristics of insomnia?
- Difficulty initiating or maintaining sleep
- Waking earlier than desired
- Difficulty at least 3 nights per week for at least 3 months
- Daytime impairment due to sleep difficulty
211
What is delayed sleep phase syndrome?
- When a persons sleep is delayed 2+ hours beyond socially acceptable bedtime
- Typically seen in teenagers
212
What is the most likely cause of narcolepsy?
Autoimmune
213
What is the major marker of narcolepsy?
REM sleep during 2+ daytime naps
Dysfunctional switching from REM --> wake during sleep
Patients are mentally awake but physically in REM
214
What other syndromes does periodic limb movement occur in?
- Narcolepsy
| - OSA
215
What should be tested medically in periodic limb movement disorder?
- Iron/anemia
| - Kidney/Liver Function
216
When is PSG appropriate over HST?
- Paroxysmal arousals
- Sleep disruption related to seizure
- Parasomnia
- PLMS narcolepsy
- Central sleep apnea syndrome
217
What EEG characteristics are common in N1?
Vertex sharp waves
218
What EEG characteristics are common in N2?
Sleep spindles
| K complexes
219
What EEG characteristics are common in N3?
Slow wave activity
220
What EEG characteristics are common in REM?
Sawtooth waves
221
Can CPAP prevent CV events in patients with moderate to severe OSA + CVD?
No, not compared to usual care alone
222
What is the difference between APAP and BPAP?
APAP: Automatic - range rather than one single pressure, fluctuates automatically
BPAP: 2 pressures, one for inhalation and lower for exhalation
223
Who may benefit from BPAP?
People with lung disorders (COPD) or CHF
224
What is central sleep apnea?
Cessastion of respiratory drive resulting in a lack of respiratory movement/effort
The brain doesn't tell the muscles to breathe
225
What does everyone who has central sleep apnea have periods of?
Respiratory alkalosis
226
What is the LAST resort for central sleep apnea treatment after APAP, CPAP, BPAP?
ASV Therapy - Adaptive Servo Ventilation Therapy
Adjusts pressure delivery based on detection of apneas
Reduces PS during hyperpnea to increase CO2 levels above apneic threshold
227
What is the minimum required follow up after delivery of a MAD?
Phone contact within 7 days to assess adherence and tolerance
228
How is basic respiration controlled?
Carotid body and aortic arch and other chemoreceptors at the base of the brain sense levels of O2 and CO2, then send signals via glossopharyngeal and vagus nerves to the brain, which then send signals to the phrenic and intercostal nerves to control respiration
229
What happens to the body's response to hypoxia and hypercapnea at night?
Breathing settles - get a small drop in PO2 and rise in PCO2
Settles even worse during REM
230
How does the genioglossus compare in patients with OSA vs. patients without?
Increased genioglossus muscle activity to try to keep the airway open
231
What is the first line therapy for kids with airway issues?
Tonsillectomy
232
What is the meuller maneuver?
Hold nose with mouth closed and try to suck in
The airway will collapse due to negative pressure in upper airway
233
What is the narrowest part of the upper airway?
Nose - 20-50% of airway resistance is here
234
What does poiseuille's law show with regards to the nose?
Small changes in the radius of the airway can create massive changes in airflow
235
How might we know if turbinates are contributing to breathing issues?
If the patient can't tell which side of the nose they are having trouble breathing through
236
How do we determine if the obstruction is at the nasal valve?
Cottle maneuver
Pull side of cheek laterally on the side of interest to determine of obstruction is at valve or deeper inside nasal cavity
237
Will people with nasal obstructions respond better or worse to OAT?
Women who complained of nasal obstruction were 9 TIMES LESS LIKELY to respond to OAT
238
What is the purpose of a drug induced sleep endoscopy?
- Guide interventions (surgical or oral appliance)
- Analyze surgical failures
- Analyze CPAP or OA failures
239
What are the goals of nasal surgery for OSA?
- Improve nasal airway
- Resolve snoring
- Improved SDB subjective symptoms
- Improve CPAP/OA compliance
240
What is a non-surgical way to stabilize the nasal valve?
Do nasal medications improve snoring/OSA?
241
Do nasal dilators impact OSA/snoring?
Do NOT impact OSA, but may improve snoring
242
Does surgical therapy for nasal obstruction improve sleep disordered breathing?
Improves subjective indicators (snoring, sleepiness, quality of life)
Does NOT improve objective indicators
243
What IS the benefit of nasal surgery with OSA?
Can facilitate CPAP use if nasal obstruction is the factor limiting compliance
244
Is soft tissue surgery effective in treating patients with OSA?
<50% effective
245
What do you remove in the classic UPP?
- Tonsils
| - Sometimes remove the uvula
246
Who does UPP work great for?
- Large tonsils
| - Small tongues
247
What are the functions of the uvula?
- Sensation
- Mucous production
- Speech
- Swallowing
248
What can happen to speech if we remove a portion of the soft palate?
Can become hypernasal
249
Does MMA surgery reduce AHI?
Yes
250
How does a tracheotomy affect patients with OSA?
Decreases mortality in patients with severe OSA
251
What are some other skeletal surgeries sometimes used to treat patients with OSA?
- MMA
- Genioglossus advancement
- Hyoid suspension
- Transpalatal advancement
- Tracheotomy
252
What is hypoglossal nerve stimulation?
Implantable device goes into right upper chest and reaches out to hypoglossal nerve and intercostal muscles
253
Who is NOT a good candidate for hypoglossal nerve stimulation?
Patients with concentric collapse
So need to undergo DISE before deciding to proceed with hypoglossal nerve stimulation
254
How does weight loss affect severity of apnea?
10% weight reduction leads to 25% reduction in severity of apnea
255
What are the 4 key phenotypes that contribute to OSA?
- Anatomically narrow/collapsible
Nonanatomic:
- Ineffective upper airway muscle dilator
- Unstable respiratory control (high loop gain)
- Low arousal threshold
256
What % of apneics are of the anatomically narrow/collapsible phenotype?
30%
257
What % of apneics have collapsibility similar to non-apneics?
19%
258
What % of apneics have the non-anatomic phenotype?
70%
259
What % of apneics have ineffective upper airway dilator muscle function?
36%
260
What can overcome high Pcrit?
Robust muscle responsiveness
261
Do nasal medications improve snoring/OSA?
No
262
Can individuals with high Pcrit and poor muscle control benefit from OAT alone?
No
263
What % of apneics exhibit the high loop gain phenotype?
36%
264
Is cortical arousal necessary to restore airflow?
No
20% of adult events resolve without arousal
50% of children events
90% of infant events
265
What is the PALM scale?
Used to encourage targeted treatment of OSA
P: Pcrit (high)
A: Arousal (low)
L: Loop Gain (high)
M: Muscle response - ineffective (low)
266
How does the airway length affect collapsibility?
Longer airway = increased collapsibility
Lower hyoid = increased collapsibility
267
Is tongue stiffness higher or lower in apneics?
Lower
268
What is the difference between thermal acrylic and thermacryl?
Thermal acrylic is rigid at room temperature, flexible at mouth temperature. May lose retention with time
Thermacryl is rigid at mouth temp, fluid at 160 degrees
269
What % of patients improve after UPPP?
40%
270
What % of patients get worse after UPPP, and why?
10%
Due to late circumferential scarring
271
How does weight gain affect AHI?
10% weight gain leads to a 32% increase in AHI
10% weight loss leads to a 26% decrease in AHI
272
How does overbite/overjet change with OAT?
Both decrease
273
How do the maxillary incisors change with OAT?
Flare lingually
274
How do the mandibular incisors change with OAT?
Flare labially
275
How do maxillary molars change with OAT?
Tip distally
276
How do mandibular molars change with OAT?
Tip mesially - can extrude distal cusp and lead to an open bite
277
When should you discontinue oral appliance therapy?
- Not tolerant/unwilling
- Limitations in ROM due to TMJ
- Orthodontic changes and pt chooses to stop
- Significant changes in periodontal health
- Oral surgery, oral cancer treatment
- AHI gets worse
- Pt has unrealistic expectations
- Uncontrollable gag reflex
- Physician alters treatment plan due to change in patient's medical condition
278
Do women have more or less success with OAT than men?
MORE, but they are more likely to abandon treatment earlier than men due to side effects
279
How much force does 1mm of mandibular advancement put on teeth?
1.18 N
Teeth can move with as little as 0.9 N of force
280
What is the compliance rate with OAT at 5 years?
50%
281
Do overjet and overbite continually reduce throughout treatment?
Overjet does, overbite changes wane
**The amount of total change in overjet is significantly correlated to initial AHI
282
What are some predictors of negative bite change?
- Frequency
- Hard splints
- Smaller pre-treatment overbite and overjet
- Number of teeth
- Larger advancement
- Device design
283
How do the contacts change over time with OAT?
- Decreased posterior occlusal contacts
| - Increase in anterior contacts as overjet is reduced
284
When does most tooth movement tend to concentrate?
Around the 2 year mark after starting OAT
285
When do most symptoms occur with OAT?
Most get better at 3 months
At 6 months, some will have posterior open bites, but by 1 year very few even notice
286
At what level of protrusion do side effects increase?
50%
Between 50-75% protrusion there isn't a lot of reduction in AHI
287
What could be reasons for dry mouth with OAT?
- Medication (diuretics, anticholinergics)
- Alcohol
- Obligate mouth breathing
- Unable to achieve lip seal
288
What are some management options for dry mouth with OAT?
- Xylimelts, Salagen
- Close anterior opening
- Reduce vertical to improve lip competency
289
Does most dry mouth with OAT self correct?
Yes - give it a few days
290
What are some possible causes of unilateral open bite with OAT?
- Muscular dysfunction (lateral pterygoid on ipsilateral side in spasm)
- Left side TMJ disc recapture
291
What are some management options with unilateral open bite with OAT?
- Rule out lateral pterygoid spasm
- Ensure equal advancement
- Lessen advancement
- Discontinue appliance use and see if open bite resolves
292
- Initial OA setting too far advanced
- Uneven contact of posterior pads
- Too much advancement at one time (lower increment necessary)
What are some potential causes of too much pressure on front teeth/Masseter soreness?
- Initial OA setting too far advanced
- Uneven contact of posterior pads
- Too much advancement at one time (lower increment necessary)
293
Where does patient normally feel pain if there is too much advancement initially?
TMJ, not muscles
294
How does sleep architecture change when sleep time is insufficient?
It doesn't
295
When does dreaming occur?
All stages, but most dreams that are remembered occur in REM
296
How does the ratio of NREM to REM change as we get older?
Increased NREM, less REM
This is why we get exhausted as we get older - we aren't getting restorative sleep
297
Do bottle or breast fed newborn babies sleep longer?
Bottle
Average is 14 hrs for babies
298
What does a newborn's sleep wake cycle depend on?
- Hunger
| - Satiety
299
What's common in infant sleep?
Arousals - due to the shorter sleep cycles of 15 minutes
300
When in life does circadian rhythm begin to be influenced by melatonin?
Toddlers - 1-3 years)
301
How does adolescent sleep change?
- Reduction in slow wave sleep
| - Marked decrease in % of REM from birth to adolescence
302
What are the wavelengths like in N1 sleep?
- High Frequency
| - Low amplitude
303
What are the wavelengths like in N2 sleep?
- Lower frequency
- Higher amplitude
* *High amplitude slow wave spikes
* *Rhythmic bursts
304
In what stage of sleep is growth hormone released?
N3
Release increases as we age
305
When in sleep does sleep bruxism occur?
N1 and N2
306
What can cause sleep bruxism?
- Stimulant medications
| - SSRI
307
Who exhibits enuresis more often?
Boys more than girls
308
What is enuresis associated with?
RLS
309
What can melatonin cause?
Precocious puberty when you discontinue
310
Who experiences delayed sleep wake phase disorder more often?
Males > Females
311
Who suffers from insomnia more often, girls or boys?
Girls
312
How much more likely are preterm babies to have OSA?
3-5X
313
What are some risk factors for upper airway obstruction?
- Forward head posture
- Retrognathic mandible
- Increased lower anterior face height
- Inferior portion of the hyoid bone
314
How does OSA affect the inflammatory response?
Children with OSA have increased inflammatory cell proliferation
315
What are the greatest cardiovascular sequelae after OSA?
What is the secondary cardiovascular sequelae after OSA?
316
Does cephalometry provide any predictive value for apnea diagnosed by PSG in a child?
No
Neither does CBCT because no standardized tongue position or threshold for airway volume
317
Nocturnal oximetry at is overestimating AHI at what levels?
Low levels
318
How do the definitions of AHI change in children v. adults?
* Apnea: Pause in respiration for 2 breathes v. 10 seconds
* Hypopnea: Reduction of airflow by 30% for 2 respiratory cycles, accompanied by reduction of O¬2 saturation by 3% or an arousal
* AHI: Includes both obstructive and central events
* Obstructive Sleep Related Hypoventilation: >25% of total sleep time spent with PCO2 above 50 mm Hg
* Arousal: Shift in EEG for at least 3 seconds
* Periodic Breathing: 3+ episodes of central apnea lasting more than 3 seconds separated by at least 20 seconds of normal breathing
319
What are some CPAP skeletal and dental changes in kids?
320/386
Play
Shuffle
Options
- Maxillary retrusion
- Counterclockwise tipping of the palatal plane
- Flaring of the maxillary incisors
320
What is the secondary cardiovascular sequelae after OSA?
Pulmonary HTN
321
What are some predictors of poor outcomes after tonsillectomy?
- High arched palate
- Delayed treatment
- Mallampati scores of III and IV
- High pre-treatment RDI
- Smaller mandibles
322
How does myofunctional therapy affect AHI in children v. adults?
Reduces it by 50% in adults and 62% in children
323
Does mouth taping affect OSA?
No - significant affect on snoring though
324
What can rapid maxillary expansion do?
- Reduce nasal obstruction
- Raise tongue posture
- Enlarges pharyngeal airway
- Normalizes hyoid bone position
325
What are you predisposed to if you have habitual snoring + insomnia?
Gestational HTN
326
What are you predisposed to if you have habitual snoring OR insomnia
Babies being born large for gestational age
327
Which of the following statements is TRUE regarding "arousal threshold"?
A. A person with high arousal threshold is easily awakened from sleep
B. Therapeutic strategies to raise arousal threshold could benefit OSA patients who arouse easily from respiratory loads
C. Therapeutic strategies to lower arousal threshold could benefit OSA patients who arouse easily from respiratory loads
D. Regardless of a patient's arousal threshold, arousal is necessary for airway reopening after an apnea event
B. Therapeutic strategies to raise arousal threshold could benefit OSA patients who arouse easily from respiratory loads
328
Which of the following statements is TRUE regarding lung volume?
A. During sleep, upper airway resistance increases as lung volume is reduced
B. Reduced lung volume results in an increase in caudal traction
C. Increased lung volume results in a more collapsible airway
D. There is no interaction between lung volume and pharyngeal patency in non OSA patients
A. During sleep, upper airway resistance increases as lung volume is reduced
329
Which of the following factors would contribute to the likelihood of a patient having OSA?
A. Reduced ventilatory response during an apneic arousal (low loop gain)
B. Increased upper airway dilator muscle responsiveness
C. Increased arousal threshold
D. Increased upper airway surface tension
D. Increased upper airway surface tension
330
The underlying pathophysiology of OSA is multifactorial and varies considerably between individuals. Which of the following would be a reasonable targeted therapy?
A. Sedatives for individuals with low arousal thresholds
B. Supplemental oxygen for individuals with low loop gain
C. Sedatives for individuals with high arousal thresholds
D. Supplemental oxygen for individuals with stable ventilatory control
A. Sedatives for individuals with low arousal thresholds
331
A new patient presents with a class III anterior bite that she believes was caused by use of an oral appliance for her moderately severe OSA. She explains that she is CPAP intolerant. You should immediately:
A. Refer the patient to an orthodontist
B. Advise the patient to discontinue her use of OAT
C. Ask the name of her treating DSM provider so you can make a complaint to the state dental association
D. Gather subjective and objective data until you have enough information to consider an assessment and plan
D. Gather subjective and objective data until you have enough information to consider an assessment and plan
332
A patient that you are treating for OSA with OAT presents to your office complaining that her upper and lower back teeth no longer touch when she tries to bite them together. She reports that she can only feel her front teeth touching. After examination, you conclude that this is related to contracture of her lateral pterygoid muscles bilaterally with resultant forward posturing of the mandible. Which of the following will best determine how successful you'll be in helping her re-establishment of her original occlusion?
A. Degree of original overbite
B. Length of time her muscles have been in contracture
C. Degree of original overjet
D. Class of dental occlusion at the start of treatment
B. Length of time her muscles have been in contracture
333
In response to the Epworth Sleepiness Scale, your patient reports they have a very high chance of dozing when laying down to rest in the afternoon when circumstances permit, but no other circumstance when they would doze. Out of a possible 24, your patient's score would be:
A. 1
B. 2
C. 3
D. 4
C. 3
334
During a clinical examination, you note that your patient has missing 3rd molars and short clinical crowns #18, #19, #30, and #31. These teeth are conically shaped and present a retention concern. When you consider the propulsion mechanism of your device, you may want to AVOID selecting:
A. Attached: Bilateral Compression
B: Attached: Anterior Traction
C: Attached: Bilateral Traction
D: Unattached: Bilateral Interlocking
C: Attached: Bilateral Traction
335
Accreditation of a facility represents that the DSM services provided exemplify all of the following except:
A. Proficiency
D. Productivity
C. Professionalism
D. Proper protocol
D. Productivity
336
Which of the following is NOT part of AADSM standard protocol for long term OAT care:
A. Evaluation for dental side effects
B. Recording vitals
C. Assessment of subjective symptoms
D. Assessment with objective home sleep testing
D. Assessment with objective home sleep testing
337
Common dental side effects with long term use of an oral appliance include:
A. Change in occlusal contacts
B. Mesial tipping of maxillary and mandibular molars
C. Increase in overbite and overjet
D. Generalized tooth mobility
A. Change in occlusal contacts
338
Regarding long term compliance to OAT (5 years), Marklund found that:
A. Overbite decreases continually but overjet changes wane
B. 90% of patients showed compliance at 5 years
C. Overjet decreases continually but overbite changes wane
D. Only 15% of patients abandoned OAT
C. Overjet decreases continually but overbite changes wane
339
The relationship between mandibular advancement and the forces created by the MAD as described by Cohen-Levy is:
A. Linearly related
B. Geometrically related
C. Inversely related
D. Arithmetically related
A. Linearly related
340
Which of the following cephalometric predictors is most likely to correlate to MAS success:
A. High mandibular plane angle
B. Reduced distance to hyoid bone and mandibular inferior border
C. Longer soft palate
D. Shorter anterior face height
B. Reduced distance to hyoid bone and mandibular inferior border
(Retrognathic mandible)
341
The dental explanation for occlusal contact changes while wearing an oral appliance for SRBD includes all of the following except:
A. Second molar tipping resulting in extrusion of the distal cusps causing an anterior open bite
B. Extrusion of the mandibular incisors
C. Palatal tipping of the maxillary incisors
D. Reduction in overjet due to labial tipping of the mandibular incisors
B. Extrusion of the mandibular incisors
342
Sleep architecture during the transition from infancy to preschool is characterized by which of the following changes:
A. Increase in REM sleep
B. Decrease in NREM sleep
C. Increase in SWS (slow wave sleep)
D. Circadian rhythm desynchronization
C. Increase in SWS (slow wave sleep)
343
During adolescence, which of the following is likely to occur?
A. Circadian phase advancement
B. Increase in REM sleep
C. Reduction in sleep drive
D. Increase in slow wave sleep
A. Circadian phase advancement
344
Children will typically demonstrate which of the following:
A. Higher arousal thresholds during N3 sleep
B. Decreased proportion of N3 sleep as compared to an adult
C. Lower arousal thresholds during REM sleep
D. Sleep spindle activity during N3
A. Higher arousal thresholds during N3 sleep
345
Primary enuresis in children:
A. Is pathognomonic of OSA
B. More common in girls than boys
C. Most episodes occur early in the sleep cycle
D. Incidence increases with age
C. Most episodes occur early in the sleep cycle
346
Different regions of the brain are affected by chronic sleep loss. Which region of the brain is most likely to be affected by sleep loss resulting in risk taking by the adolescent?
A. Brainstem
B. Prefrontal cortex
C. Amygdala
D. Striatum
D. Striatum
347
The scammon curve can best be used to explain how:
A. Class II malocclusions are associated with OAT
B. The child's airway is anatomically at risk for OSA
C. The hyoid bone moves inferior during growth
D. The palatal shelves respond to RME
B. The child's airway is anatomically at risk for OSA
348
Adenotonsillary hypertrophy (AT) is most often associated with which growth pattern:
A. Bimaxillary protrusion
B. Mandibular prognathism
C. Increased anterior facial height
D. Skeletal brachycephalic
C. Increased anterior facial height
349
The BEARS screening tool:
A. Is a screening tool for sleep disordered breathing only useful for children under 5 years of age
B. Asks trigger questions about bedtime problems, ESS, awakenings, REM stage, and snoring
C. Is a screening tool for sleep disordered breathing for children ages 2-18
D. Divides children into 4 age categories
C. Is a screening tool for sleep disordered breathing for children ages 2-18
350
In children, use of nocturnal oximetry is problematic because:
A. Children are more likely to desaturate relative to adults
B. Oximetry tends to overestimate AHI at low severity and underestimate AHI at high severity
C. Children show fewer movements in sleep than adults
D. There is excellent sensitivity but poor specificity
A. Children are more likely to desaturate relative to adults
B. Oximetry tends to overestimate AHI at low severity and
BOTH ARE CORRECT
351
Compared to adults, children with OSA have:
A. Better preservation of sleep architecture
B. More obstructive apneas
C. More cortical arousals
D. More insomnia complaints
A. Better preservation of sleep architecture
352
A predictor of poor outcomes of adenotonsillectomy procedures for children with OSAS is:
A. Early treatment
B. Mallampati scores of I or II
C. Low pretreatment AHI
D. High arched palate
D. High arched palate
353
The "Flip-Flop Switch" metaphor of sleep describes:
A. The balance between slow wave sleep and REM stage sleep
B. A long, slow progressions from wakefulness to NREM stage 1 sleep
C. Mutual inhibition between wake promoting neurons and sleep promoting neurons
D. The abrupt suppression of actigraphy activity at the onset of REM sleep
E. A and C
E. A and C
354
Which statement is true regarding Melatonin:
A. Melatonin is necessary for sleep
B. Melatonin is released from the Pineal Gland
C. Increased release of Melatonin at end of day is primary factor in sleep drive
D. Caffeine is a non-specific melatonin blocker
B. Melatonin is released from the Pineal Gland
355
Which of the following is true regarding REM stage sleep?
A. Premature infants spend less time in REM stage sleep than full term neonates
B. Full term infants spend 80% of total sleep time in REM stage sleep
C. The percentage of REM stage sleep falls during childhood, and plateaus at age 10
D. Normal REM stage sleep as a percentage of total sleep time in adults (ages 20-69) is 25%
D. Normal REM stage sleep as a percentage of total sleep time in adults (ages 20-69) is 25%
356
Which of the following is true regarding sleep stages?
A. Sleep spindles and k-complexes appear in NREM Stage 2
B. Vertex sharp waves are abundant in REM Stage
C. PGO and saw-tooth waves are most noted in slow wave sleep
D. High frequency EEG (alpha-beta) is characteristic of NREM Stage 3
A. Sleep spindles and k-complexes appear in NREM Stage 2
357
Central Chemoreceptors contribute to respiratory homeostasis and
A. Are located in the midbrain
B. Are sensitive to CO2 and H+
C. Maintain CO2 in a wide physiologic range
D. Detect changes in spinal fluid volume
B. Are sensitive to CO2 and H+
358
Which of the following statements is true about the Carotid Body?
A. It is the primary Central Chemoreceptor
B. Hypoxia triggers suppression of minute ventilation
C. Is sensitive primarily to hypoxia
D. Is sensitive primarily to changes in CO2, pH and temperature
C. Is sensitive primarily to hypoxia
359
Which of the following statements is true regarding OSA prevalence?
A. After age 50, gender differences become even more pronounced with the ratio of males to females increasing
B. After age 60, BMI becomes an even more important variable
C. OSA is the most common chronic, non-communicable disease in the USA
D. Menopausal hormone changes do not appear to impact OSA risk
C. OSA is the most common chronic, non-communicable disease in the USA
360
Which statement is true regarding tools use to screen for Sleep Related Breathing Disorders?
A. The Epworth Sleepiness Score is specific for SRBDs
B. The Berlin questionnaire may be requested by private payers
C. The Berlin questionnaire includes a question on hypertension
D. A high score on the STOP-BANG questionnaire indicates high probability of mild to moderate OSA
C. The Berlin questionnaire includes a question on hypertension
361
Which of the following criteria must be met to score a central apnea during PSG according to the AASM Guidelines?
```
A. At least 90% reduction in flow signal
B. At least 90% reduction in flow signal for at least 10 seconds
C. Evidence of continued effort
D. No evidence of effort
E. B and C
F. B and D
```
F. B and D
362
Which of the following AASM guidelines is recommended by CMS to score a hypopnea during PSG?
A. At least 30% reduction in flow signal for at least 10 seconds
B. An arousal
C. At least a 3% oxygen desaturation from baseline
D. At least a 4% oxygen desaturation from baseline
E. A and B or A and C
F. A and D
F. A and D
363
During PSG, AASM guidelines define an obstructive hypopnea when which of the following criteria is met
A. Snoring
B. Inspiratory flattening
C. Thoracoabdominal pardox
D. Any of the above
D. Any of the above
364
Which of the following statements is true regarding AASM guidelines for scoring Respiratory Effort Related Arousals, RERAs?
A. CMS recognizes RERAs as hypopneas
B. The clinical definition is precisely defined but the research definition is not agreed upon
C. Breaths with progressively decreasing effort for more than 10 seconds leading to a desaturation and arousal
D. Breaths with increasing rate or flattening for more than 10 seconds leading to an arousal, not meeting criteria for apnea or hypopnea
D. Breaths with increasing rate or flattening for more than 10 seconds leading to an arousal, not meeting criteria for apnea or hypopnea
365
A patient that presents with symptoms indicating a risk for moderate to severe OSA and a history of stroke and insomnia. The AASM recommends:
A. The patient submits for HST since it has high sensitivity and specificity for detecting OSA
B. The patient submits for HST since PSG is likely to aggravate the insomnia
C. The patient submits for PSG in conjunction with a sleep evaluation
D. All patients should have PSG if their insurance will cover it
C. The patient submits for PSG in conjunction with a sleep evaluation
366
Which of the following is true regarding types of diagnostic studies for identification of sleep related breathing disorders?
A. An in-lab polysomnogram may be either type I or type II
B. A type IV study gathers more data than a type II study
C. A type III study has a minimum of 4 parameters and at least 2 channels of respiration
D. A type II study has a minimum of 6 physiologic variables but no scalp wires
C. A type III study has a minimum of 4 parameters and at least 2 channels of respiration
367
The SCOPER classification system
A. Is helpful in determining parameters for in-lab polysomnogram testing
B. Categorizes Sleep, Cardiovascular, Oximetry, Pulse, Effort and Respiratory
C. Classifies and evaluates sleep testing devices for out of center applications
D. Was named for its inventors, Drs Smythe, Carlson, Orace, Peters, Edwards and Rafael
C. Classifies and evaluates sleep testing devices for out of center applications
368
When looking at the co-occurrence of OSA and insomnia, which of the following statement are true?
A. Co-occurrence is consistently found to be 65% between groups seeking evaluation for sleep apnea and groups seeking evaluation for insomnia
B. Those with a primary complaint of insomnia tend to be male
C. Those with a primary complaint of OSA tend to be more likely to use alcohol than people with OSA only
D. There is a decreased morbidity and impairment than that which is present with either disease alone
B. Those with a primary complaint of insomnia tend to be male
369
Treatment strategies for insomnia in the presence of OSA should make note of the following true statement:
A. Hypnotics, such as benzodiazepines, can have adverse effects on nocturnal respiration, thus exacerbating OSA
B. The newer nonbenzodiazepine agents, such as zolpidem and eszopiclone, appear to increase AHI
C. Cognitive Behavioral Therapy, CBT, is non-pharmacologic and therefore poses no risk
D. CBT is reported to be more effective for insomnia in the presence of OSA than when used for insomnia without comorbidities
A. Hypnotics, such as benzodiazepines, can have adverse effects on nocturnal respiration, thus exacerbating OSA
370
Which of the following statements is true about sleep restriction?
A. Approximately 30% of Americans sleep less than 7.5 hours per night
B. Partial sleep deprivation has been studied more extensively than total sleep deprivation
C. Sleep restriction does not impact sleep architecture
D. Significant cognitive dysfunction can occur if sleep is repeatedly restricted to less than 7 hours per night
D. Significant cognitive dysfunction can occur if sleep is repeatedly restricted to less than 7 hours per night
371
Which of the following is true regarding the Muller's maneuver?
a. It is used to distinguish between OSA and CSA
b. After forced expiration, an attempt at inspiration is made with closed mouth and nose
c. After maximum inspiration, an attempt at expiration is made with closed mouth and nose
d. It helps to clear the Eustachian tubes during dramatic altitude changes
b. After forced expiration, an attempt at inspiration is made with closed mouth and nose
372
What can be concluded regarding nasal obstruction and OSA?
a. Nasal obstruction is associated with snoring
b. Nasal obstruction is associated with OSA
c. Nasal obstruction is associated with lowered concentration of pulmonary nitric oxide
d. All of the above
d. All of the above
373
What can be concluded regarding nasal resistance and treatment of OSA with OAT?
a. Lower nasal resistance is a predictor of improved OAT response
b. Higher nasal resistance is a predictor of improved OAT response
c. Women with higher nasal resistance show improved response to OAT
d. Nasal resistance increases with protrusive positioning of the mandible
a. Lower nasal resistance is a predictor of improved OAT response
374
Which of the following is listed from highest to lowest level of evidence?
A. Case reports, Case series, Case control studies, Cohort studies
B. Randomized controlled double-blind studies, Systematic reviews/Meta-analyses, Cohort studies
C. Systematic reviews/Meta-analyses, Cohort studies, Case reports
D. Randomized controlled double-blind studies, Case series, Cohort studies
C. Systematic reviews/Meta-analyses, Cohort studies, Case reports
375
A study in which the experiences of individuals with and without a particular disease are analyzed retrospectively to identify putative causative events (exposures) is called a:
A. Systematic Review
B. Meta-analysis
C. Case reports
D. Case-control studies
D. Case-control studies
376
In a Randomized controlled trial, if there is incomplete randomization between the intervention group and the control group, this is known as:
A. Selection bias
B. Performance bias
C. Exclusion bias
D. Detection bias
A. Selection bias
377
If a test for a disease has a sensitivity of only 40 percent, it means that:
A. It has very few false negative results
B. Fails to find the disease 60 percent of the time
C. It has high specificity
D. Should never be used
B. Fails to find the disease 60 percent of the time
378
```
What percentage of patients with hypertension suffer from OSA?
A. 25%
B. 30%
C. 40%
D. 50%
```
30-50% ?????
379
Development of a unilateral posterior open bite with use of an oral appliance may be related to:
A. Reduction of a dislocated TMJoint disc on the ipsilateral side
B. Lateral pterygoid spasm on the contralateral side
C. Reduction of a dislocated TMJoint disc on the contralateral side
D. Medial pterygoid spasm on the ipsilateral side
A. Reduction of a dislocated TMJoint disc on the ipsilateral side
380
In determining treatment options for TMD symptoms triggered by use of an oral appliance for OSA, the dentist should initially recommend:
A. Discontinued use of the appliance until the adverse symptoms resolve.
B. Continued use of the appliance with watchful waiting and application of palliative exercises and stretching.
C. Use of appropriate medication to mask adverse symptoms in order to continue advancement.
D. Increase in vertical dimension to prevent the patient from clenching on the appliance.
B. Continued use of the appliance with watchful waiting and application of palliative exercises and stretching.
381
Patient report of dry mouth in the morning with OAT may be related to all of the following EXCEPT:
A. Obligate mouth breathing
B. Medications
C. Lip competence
D. Insufficient vertical
D. Insufficient vertical
382
In contrast to young adults, older sleepers have:
A. More stage III sleep.
B. More REM stage sleep.
C. Later bedtimes.
D. More arousals from sleep.
D. More arousals from sleep.
383
Standard AADSM protocol for post delivery follow up of the oral appliance involves:
A. a phone call within two weeks of delivery to the patient
B. an office visit within two weeks of delivery
C. an office visit within one month of delivery
D. a HSAT or pulse oximetry recording acquired within 90 days
C. An office visit within one month of delivery
384
Adjunctive strategies to improve therapeutic outcomes of oral appliance therapy for sleep related breathing disorders commonly include all of the following EXCEPT:
A. Allergic rhinitis management
B. Reduction in BMI
C. Hypoglossal nerve stimulation
D. Positional Therapy
C. Hypoglossal nerve stimulation
385
When discussing device selection with a patient you should address all of the following EXCEPT?
A. Available space for and position of the protrusion mechanism
B. Missing teeth and compromised teeth
C. AHI and percentage of sleep time below 88% oxygen saturation
D. Patient preference
C. AHI and percentage of sleep time below 88% oxygen saturation
386
Who publishes the CPT code book?
A. The Centers for Medicare & Medicaid Services
B. The American Medical Association
C. The Office of the Inspector General
D. The Durable Medical Equipment Service
E. The American Academy of Sleep Medicine
B. The American Medical Association
