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Obstructive Sleep Apnea Flashcards

1
Q

6 RECOMMENDATIONS:
1. We recommend that sleep physicians prescribe —, rather than no therapy, for adult patients who
request treatment of primary snoring (without obstructive
sleep apnea). (STANDARD)
2. When oral appliance therapy is prescribed by a sleep
physician for an adult patient with obstructive sleep apnea,
we suggest that a qualified dentist use a …(GUIDELINE)
3. We recommend that sleep physicians consider prescription
of —, rather than no treatment, for adult
patients with obstructive sleep apnea who are intolerant
of CPAP therapy or prefer alternate therapy. (STANDARD)
4. We suggest that qualified dentists provide oversight—
rather than no follow-up—of oral appliance therapy in adult
patients with obstructive sleep apnea, to survey for dental
related side effects or — changes and reduce their
incidence. (GUIDELINE)
5. We suggest that sleep physicians conduct follow-up sleep
testing to improve or confirm treatment efficacy, rather than
conduct follow-up without sleep testing, for patients fitted
with oral appliances. (GUIDELINE)
6. We suggest that sleep physicians and qualified dentists
instruct adult patients treated with oral appliances for
obstructive sleep apnea to return for periodic office visits—
as opposed to no follow-up—with a qualified dentist and a
sleep physician. (GUIDELINE)

A

oral appliances
custom, titratable
appliance over non-custom oral devices.
oral appliances
occlusal

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2
Q
  1. Obstructive:
A

absence of airflow despite
respiratory effort- Dentist may treat

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3
Q
  1. Central:
A

absence of airflow & No respiratory
effort (brain control of respiration is
abnormal) –
treated by M.D. with
medications

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4
Q
  1. Mixed:
A

combination of obstructive & central

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5
Q

OSA
1. Is not treated in the pre-doctoral or resident
clinics
2. Can be treated by

A

general dentists who are
certified in sleep medicine with knowledge
of Medical Billing. CE coursework is required
to treat Obstructive sleep apnea.

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6
Q
  1. Diagnosis of OSA MUST be made by a
A

licensed physician (NOT a dentist) & a
Polysomnogram (PSG) sleep study must be
ordered by the M.D. as well as treatment
studies.
2. Requires a National Provider Identification
Number (NPI) and dental license to bill for
this medical condition
3. Requires advanced training to TREAT &interpret the sleep studies to determine
efficacy of sleep appliance.

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7
Q

OSA
 is a very common and potentially
life-
threatening medical disorder (i.e. heart
attack, stroke)
 occurs when

A

tissue in the back of the throat
collapses and blocks the airway, reducing the
amount of oxygen delivered to all of your
organs including your heart and brain

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8
Q

 Apnea-

A

cessation of oronasal airflow for > 10
seconds

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9
Q

 Hypopnea-

A

decrease in airflow of 50% for
>10 seconds with >3% O2 desaturation

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10
Q

 Apnea Index:

A

the average number of apneas per
hour of sleep (AI)

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11
Q

 Apnea-Hypopnea Index:

A

the average number of
apneas and hypopneas per hour of sleep (AHI)

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12
Q

 Respiratory Disturbance Index:

A

AHI + RERAs
(respiratory effort related arousals)

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13
Q

 Requires Treatment:

A

AHI>5, Respiratory
Disturbance Index is elevated

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14
Q

 Oxygen Saturation (SaO2):

A

the fraction of a
total hemoglobin (HB) in the form of HbO2 at
a defined pressure of oxygen (PO2).

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15
Q


Partial pressure of arterial Oxygen (PaO2):

A

the part of total blood gas pressure exerted
by oxygen gas. Normal partial pressure of
oxygen in arterial blood is 95-100mmHg. It
is lower in individuals with asthma,
obstructive lung disease & certain blood
diseases.

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16
Q

 NORMAL SaO2 in AWAKE individual:
 SaO2 Desaturation Scale in OSA:
 Mild:
 Moderate:
 Severe:

A

> 93%

85-89%
80-84%
<80%

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17
Q

 Certain individuals with Obstructive Sleep
Apnea will experience decreased Oxygen
saturations causing Hypoxia during sleep.
Decreased SaO2 levels <–% are known to
compromise organ function (i.e. brain and
heart).
 Continued low oxygen levels may lead to
respiratory or cardiac arrest. —
is common

A

80
Atrial fibrillation

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18
Q

Epidemiology
1. Affects –% of adult population in
the U.S. (20 million Americans)
2. Male: Female prevalence is –
3. Menopause: Occurs x more
frequently due to progesterone
levels
4. Insomnia: –%
5. Age: increases with — age
6. — Body Mass Index (BMI)

A

4
2-3:1
2x
10
middle
High

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19
Q

incidence of snoring
By Age 40:
 –% of Males
 –% of Females
By Age 60:
 –% of Males
 –% of Females

A

40
20

60
40

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20
Q

Snorers : Increased Risk
HTN –x
sudden death –X
CVA’s (stroke) –X
ischemic heart disease –X

A

2
4
10
2

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21
Q

Consequences of OSA
MEDICAL:
(4)

A
  1. DEATH
  2. Cardiovascular -
    HTN, Myocardial
    Infarction (MI), Stroke
    (CVA)
  3. Diabetes, obesity,
    depression
  4. Medical costs - 2.5-
    3x hospital days and
    2x medical costs
    ($3.4 billion)
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22
Q

Consequences of OSA
PERSONAL IMPACT:
1. Motor Vehicle
Accidents-corrects
with —
2. Psychosocial/economic
failure - –% fell asleep
at work, –% fired or
demoted.
3. Lost productivity &
workplace accidents:
$150 billion

A

CPAP
34,11

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23
Q

skipped
Medical eval incudes (7)

A
  1. History and Epworth Sleepiness Scale
  2. Physical exam: neck size, BMI, ENT
    evaluation
  3. Polysomnogram with “split night” titration
    wearing the CPAP mask during 2nd half of
    study
  4. Imaging: dynamic MRI- may be done
  5. Dental Exam:
  6. TMD Exam
  7. Panorex &/or Lateral Tomography or CBCT
    of TMJ
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24
Q

symptoms and signs of OSA
Primary
(3)
Secondary
(9)

A

 snoring
 hypersomnia
 breathing pauses,
choking

 hypertension
 Gastric esophageal
disease (GERD)
 night sweats
 headaches
 nocturia
 decreased libido
and/or impotence
 decreased memory
 Irritability
 Atrial fibrillation

25
symptoms (5)
 Daytime somnolence  Snoring  Chronic fatigue  Neurocognitive  Dysfunction
26
skipped role of dentists (6)
1. Recognize OSA symptoms and refer to sleep physician 2. Manage possible consequences of OSA e.g. Bruxism, GERD and oro-facial pain 3. Ability to recommend the appropriate Mandibular Advancement Devices (MADs) 4. Coordinate with a sleep physician and monitor the patients physical and mental health 5. Able to understand the results of sleep studies 6. Managing the possible side effects of using MADs
27
Dentists evaluate airway space regularly & may notice restricted space LOOK FOR: (8)
Enlarged tonsils Enlarged tongue Elongated uvula Decreased airway space When patient says “Ahh” Elongated soft palate V shaped palate Micrognathia/Retrognathia
28
upper airway patency during sleep depends on (2)
 Upper airway size & stiffness  Neuronal control of pharyngeal muscles
29
 If you observe: (1) restricted airway space or (2) retrognathia, ask patient about (4)  Refer patient to physician for an evaluation and polysomnogram sleep study (PSG)- spent overnight in a sleep laboratory. As a dentist, you cannot order the sleep study.
snoring, gasping for air, poor sleep quality and daytime fatigue
30
--- will demonstrate size and position of tongue and narrowing of oropharynx
MRI
31
polysomnography (PSG) (3)
1. Is REQUIRED by insurance prior to treatment (pre-treatment), M.D. must order PSG 2. Is REQUIRED at end of completion (post- treatment) to determine efficacy of oral sleep apnea appliance although some insurance will accept the home sleep study 3. May be ordered while titrating appliance or a home sleep study may be authorized
32
polysomnography (PSG)  Monitors: (7)
 Sleep stages  Respiration  Oxygen saturation  Nasal & oral airflows  Electrocardiography (EKG)  Electroencephalography (EEG)  Sleep position
33
skipped predictors for favorable response to MAD Clinical (6) Craniofacial (3)
 Younger age  Lower BMI  Lower neck circumference <17”  Positional OSA  Lower AHI (not consistently)  Increased protrusion  Larger oropharynx  Smaller overjet  Short soft palate length
34
contraindications for sleep apnea devices (4)
1. Insufficient teeth to support device however can be made if 1 arch is edentulous 2. Periodontal problems causing tooth mobility 3. Active temporomandibular joint disorder (TMD) or severe arthritis 4. Limited maximum protrusion < 6mm
35
--% of drivers admit to falling asleep at wheel
20
36
Sleep ranks among the -- most important considerations in maintaining good health
3
37
sleep  --% of U.S. population  experiences intermittent or regular sleep problems  --% of these adults have NEVER discussed sleep problems with their physician  Societal bias equates sleepiness with LAZINESS
62 80
38
skipped Sleep disorder symptoms --% Insomnia --% < 7 hours sleep duration --% Non-restorative sleep --% Snore nightly/ weekly --% Daytime fatigue /sleepiness --% Driving while sleepy --% -Accidents/near accident --% Fatigue affects intimacy --%
75 33-54 40 38 32 37 60 4 20
39
Apnea Hypopnea Index (AHI): Obstructive Sleep Apnea Rating 0-4 events per hour: 5-15 events per hour: 16-30 events per hour: >30 events per hour:
No OSA Mild Moderate Severe
40
dx of sleep apnea (5)
1. Spouse or family member reports snoring/apnea 2. Medical History OR Hypertension raises suspicion 3. Dental examination reveals upper airway anatomical abnormalities 4. Degree of sleepiness can be assessed with a short questionnaire (i.e. Epworth Sleepiness Scale) 5. If the above raise suspicion for sleep- related disorder, physician will refer to a sleep laboratory
41
approved tx (5)
1. CPAP(continuous positive airway pressure)/Bilevel positive pressure (BiPAP)- gold standard 2. ENT surgery – uvulopalatoplasty (UVPP), tonsillectomy, deviated septum surgery, turbinectomy, genioglossus advancement or implanted nerve stimulator 3. Maxillomandibular advancement surgery 4. Mandibular advancement devices (MADs) 5. Inspire neurostimulator that stimulates glossopharyngeal nerve to protrude tongue so airway space remains open
42
continuous positive airway pressure (CPAP) (3)
 Splints the upper airway pneumatically during sleep so airway does NOT collapse  Highly effective but cumbersome  Long-term compliance is 60 – 70%
43
general tx (5)
1. Altering sleep position (i.e. raise head of bed) 2. Avoidance of alcohol, muscle relaxants & sedatives or narcotics 3. Relieving nasal congestion 4. Reducing weight 5. Smoking cessation
44
CPAP intolerance  Due to: (6)
1. Claustrophobia 2. Mask leaks 3. Mask and tubing are bulky especially when changing sleep position 4. Must remove CPAP mask to use restroom 5. Contact dermatitis or allergy from mask 6. Embarrassment
45
uvulopalatropharyngoplasty (UVPP) (3)
 Surgical removal of uvula with resection of soft palate tissue to create more space  50% of patients report improved sleep apnea symptoms but not always long term  Surgery to correct deviated septum, nasal polyps, tonsillectomy and chronic rhinitis may also help
46
skipped custom sleep apnea appliances are recommended (7)
1. Numerous designs 2. Advance the mandible 3. Better tolerated by patients than CPAP 4. Better fit than soft appliances- OTC not recommended 5. Can create or exacerbate existing TMD 6. Can possibly CREATE A MALOCCLUSION 7. Medical billing for appliance
47
 Mandibular Advancement Devices (MAD):  Oral Appliance Therapy (OAT)  Titratable Thermoplastic Devices (TPD)  Over the Counter Devices-
Custom –made by Dentist- fully adjustable NOT RECOMMENDED-available directly to the patient( non-custom made) MAY NOT BE TITRATABLE
48
custom appliances (OA)  OA therapy is most effective for patients with ---  OA therapy may also be efficacious for patients with --- OSA
mild/moderate OSA. severe
49
Computer-Aided Design and Computer Assisted Manufacturing (3)
 The mandibular advancement device is custom-made using a computer-aided design and manufacturing (CAD/CAM) process.  Use Trios scanner or Impressions/models upload scans into computer- send the dental lab  Design is “milled” on 3-D printer by the dental laboratory using medical grade nylon or acrylic *Computer-Aided Design and Computer Assisted Manufacturing PANTHERA
50
 Only the custom appliances significantly reduced the AHI  Failure rate with prefabricated (non-custom) devices was --%  --% of patients who failed with the prefabricated device were successfully treated with the custom device.  --% of patients preferred the custom device  Vanderveken et al. AJRCCM 2008.
69 63 82
51
MOA 1. Normally made ---% of the maximum protrusion 2. Widening of the airway --- 3. Relocation of the --- laterally 4. --- displacement of the tongue base 5. Protrusion is normally accompanied with ---
50-75 laterally pharyngeal fat pads Anterior increased vertical dimension
52
Selection may be based on the following: (6)
1. Size of patient arch 2. Lack of sufficient undercuts (facial height of contour) to retain appliance 3. Number of missing teeth 4. Size/volume of appliance and size of mouth affect comfort 5. Patient preference 6. Patient allergy to acrylic or nickel- make SomnoMed Avant OR Panthera sleep appliance
53
AVANT sleep apnea appliance (3)
 Has nylon advancement rods that patient can change at home  Less driving and less appointments needed  No metal
54
appliance side effects - per patient (7)
1. Too much or too little saliva 2. Irritation on cheeks or lips by fins or rods 3. Inability to close lips 4. Jaw pain 5. Feels like a “mouth full” 6. Change in occlusion in the morning or permanent 7. Gum pain
55
follow up visits 1. Initially at --weeks & order treatment sleep study to determine efficacy of sleep appliance. Every -- months for the 1st year, and annually thereafter 2. Check compliance 3. Patient-induced damages (i.e. Due to modifications, bruxism) 4. Check oral health, occlusion and TMJ 5. Referral to a sleep physician as necessary
2-4 6
56
contraindications for sleep apnea devices (4)
1. Insufficient teeth to support device but if good bone support can be made 2. Periodontal problems causing tooth mobility 3. Active temporomandibular joint disorder (TMD) or severe arthritis 4. Limited maximum protrusion < 6mm
57
effectiveness of sleep apnea devices  METHODS:  33 consecutively treated patients were evaluated  Sleep study done 1 night without device & 1 night with device after 0.7 & 5.2 years from start of treatment  RESULTS:  -- of 33 patients experienced short-term satisfactory results with an apnea-hypopnea index (AHI)of <10 events/hour and decreased snoring  -- of 33 patients were insufficiently treated  -- of the 19 short-term satisfactorily treated patients (90%) continued treatment on a long-term basis  a significant reduction (p<0.001) in the apnea-hypopnea index from 22 to 5 events/hour was demonstrated by individuals wearing the sleep apnea device
19 14 17
58

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