Obstructive Sleep Apnea Flashcards
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)
oral appliances
custom, titratable
appliance over non-custom oral devices.
oral appliances
occlusal
- Obstructive:
absence of airflow despite
respiratory effort- Dentist may treat
- Central:
absence of airflow & No respiratory
effort (brain control of respiration is
abnormal) –
treated by M.D. with
medications
- Mixed:
combination of obstructive & central
OSA
1. Is not treated in the pre-doctoral or resident
clinics
2. Can be treated by
general dentists who are
certified in sleep medicine with knowledge
of Medical Billing. CE coursework is required
to treat Obstructive sleep apnea.
- Diagnosis of OSA MUST be made by 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.
OSA
is a very common and potentially
life-
threatening medical disorder (i.e. heart
attack, stroke)
occurs when
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
Apnea-
cessation of oronasal airflow for > 10
seconds
Hypopnea-
decrease in airflow of 50% for
>10 seconds with >3% O2 desaturation
Apnea Index:
the average number of apneas per
hour of sleep (AI)
Apnea-Hypopnea Index:
the average number of
apneas and hypopneas per hour of sleep (AHI)
Respiratory Disturbance Index:
AHI + RERAs
(respiratory effort related arousals)
Requires Treatment:
AHI>5, Respiratory
Disturbance Index is elevated
Oxygen Saturation (SaO2):
the fraction of a
total hemoglobin (HB) in the form of HbO2 at
a defined pressure of oxygen (PO2).
Partial pressure of arterial Oxygen (PaO2):
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.
NORMAL SaO2 in AWAKE individual:
SaO2 Desaturation Scale in OSA:
Mild:
Moderate:
Severe:
> 93%
85-89%
80-84%
<80%
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
80
Atrial fibrillation
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)
4
2-3:1
2x
10
middle
High
incidence of snoring
By Age 40:
–% of Males
–% of Females
By Age 60:
–% of Males
–% of Females
40
20
60
40
Snorers : Increased Risk
HTN –x
sudden death –X
CVA’s (stroke) –X
ischemic heart disease –X
2
4
10
2
Consequences of OSA
MEDICAL:
(4)
- DEATH
- Cardiovascular -
HTN, Myocardial
Infarction (MI), Stroke
(CVA) - Diabetes, obesity,
depression - Medical costs - 2.5-
3x hospital days and
2x medical costs
($3.4 billion)
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
CPAP
34,11
skipped
Medical eval incudes (7)
- History and Epworth Sleepiness Scale
- Physical exam: neck size, BMI, ENT
evaluation - Polysomnogram with “split night” titration
wearing the CPAP mask during 2nd half of
study - Imaging: dynamic MRI- may be done
- Dental Exam:
- TMD Exam
- Panorex &/or Lateral Tomography or CBCT
of TMJ
symptoms and signs of OSA
Primary
(3)
Secondary
(9)
snoring
hypersomnia
breathing pauses,
choking
hypertension
Gastric esophageal
disease (GERD)
night sweats
headaches
nocturia
decreased libido
and/or impotence
decreased memory
Irritability
Atrial fibrillation
symptoms
(5)
Daytime somnolence
Snoring
Chronic fatigue
Neurocognitive
Dysfunction
skipped
role of dentists (6)
- Recognize OSA symptoms and refer to sleep physician
- Manage possible consequences of OSA e.g. Bruxism,
GERD and oro-facial pain - Ability to recommend the appropriate Mandibular
Advancement Devices (MADs) - Coordinate with a sleep physician and monitor the
patients physical and mental health - Able to understand the results of sleep studies
- Managing the possible side effects of using MADs
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
upper airway patency during sleep depends on (2)
Upper airway size & stiffness
Neuronal control of pharyngeal muscles
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
— will demonstrate size and position of tongue and narrowing of oropharynx
MRI
polysomnography (PSG)
(3)
- Is REQUIRED by insurance prior to treatment
(pre-treatment), M.D. must order PSG - 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 - May be ordered while titrating appliance or
a home sleep study may be authorized
polysomnography (PSG)
Monitors:
(7)
Sleep stages
Respiration
Oxygen saturation
Nasal & oral airflows
Electrocardiography (EKG)
Electroencephalography (EEG)
Sleep position
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
contraindications for sleep apnea devices
(4)
- Insufficient teeth to support device however
can be made if 1 arch is edentulous - Periodontal problems causing tooth mobility
- Active temporomandibular joint disorder
(TMD) or severe arthritis - Limited maximum protrusion < 6mm
–% of drivers admit to falling asleep at wheel
20
Sleep ranks among the – most important
considerations in maintaining good
health
3
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
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
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
dx of sleep apnea
(5)
- Spouse or family member reports
snoring/apnea - Medical History OR Hypertension raises
suspicion - Dental examination reveals upper airway
anatomical abnormalities - Degree of sleepiness can be assessed with
a short questionnaire (i.e. Epworth
Sleepiness Scale) - If the above raise suspicion for sleep-
related disorder, physician will refer to a
sleep laboratory
approved tx
(5)
- CPAP(continuous positive airway pressure)/Bilevel
positive pressure (BiPAP)- gold standard - ENT surgery – uvulopalatoplasty (UVPP),
tonsillectomy, deviated septum surgery,
turbinectomy, genioglossus advancement or
implanted nerve stimulator - Maxillomandibular advancement surgery
- Mandibular advancement devices (MADs)
- Inspire neurostimulator that stimulates
glossopharyngeal nerve to protrude tongue so
airway space remains open
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%
general tx (5)
- Altering sleep position (i.e. raise head of
bed) - Avoidance of alcohol, muscle relaxants &
sedatives or narcotics - Relieving nasal congestion
- Reducing weight
- Smoking cessation
CPAP intolerance
Due to:
(6)
- Claustrophobia
- Mask leaks
- Mask and tubing are bulky especially when
changing sleep position - Must remove CPAP mask to use restroom
- Contact dermatitis or allergy from mask
- Embarrassment
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
skipped
custom sleep apnea appliances are recommended
(7)
- Numerous designs
- Advance the mandible
- Better tolerated by patients than CPAP
- Better fit than soft appliances- OTC not
recommended - Can create or exacerbate existing TMD
- Can possibly CREATE A MALOCCLUSION
- Medical billing for appliance
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
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
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
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
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
Selection may be based on the following:
(6)
- Size of patient arch
- Lack of sufficient undercuts (facial height of
contour) to retain appliance - Number of missing teeth
- Size/volume of appliance and size of mouth
affect comfort - Patient preference
- Patient allergy to acrylic or nickel- make
SomnoMed Avant OR Panthera sleep
appliance
AVANT sleep apnea appliance
(3)
Has nylon advancement rods that patient can
change at home
Less driving and less appointments needed
No metal
appliance side effects - per patient (7)
- Too much or too little saliva
- Irritation on cheeks or lips by fins or
rods - Inability to close lips
- Jaw pain
- Feels like a “mouth full”
- Change in occlusion in the morning or
permanent - Gum pain
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
contraindications for sleep apnea devices
(4)
- Insufficient teeth to support device but if
good bone support can be made - Periodontal problems causing tooth mobility
- Active temporomandibular joint disorder
(TMD) or severe arthritis - Limited maximum protrusion < 6mm
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
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