dental management of sleep apnea

DENTAL MANAGEMENT OF OSA

DR. M.SH. NABHAN

WHAT IS OBSTRUCTIVE SLEEP APNEA (OSA)?

• Sleep disorder characterized by recurrent episodes of narrowing or collapse of pharyngeal airway during sleep despite ongoing breathing efforts.

• These often lead to

• Acute derangements in blood gas disturbances

• Periodic arousal from sleep (fragmented sleep)

DEFINITIONS

• Apnea is cessation or near cessation of flow (inspiratory flow decreases to < 20%) ≥ 10 seconds

•Hypopnea is continued breathing, but ventilation decreases by 50% for ≥ 10 seconds

• Apnea-Hypopnea Index (AHI) – total number of apneas and hypopneas per hour of sleep

SLEEP DISORDERED BREATHING

•Obstructive Sleep Apnea

•Central Sleep Apnea

•Cessation of ventilation during sleep due to loss of ventilatory drive

•≥ 10 second pauses with no associated respiratory effort

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PATHOPHYSIOLOGY

So: American College of Cardiology

PATENT VS COLLAPSED AIRWAY

2006 American Academy of Sleep medicine

PATHOPHYSIOLOGY OF OSA

• Sites of Obstruction:

NASAL CAUSES

• Nasal polyps

• Deviated nasal septum

• Rhinitis

• Nasal pack

PHARYNGEAL CAUSES

•Nasopharyngeal tumor

•Enlarged adenoid

•Enlarged palatal tonsils

•Enlarged lingual tonsils

•Retropharyngeal mass

• Large tongue (myxoedema, acromegaly), micrognatheia, retrognathesia, and obesity.

LARYNGEAL CAUSES

•Tumors in the larynx

•Edema

SIGNIFICANCE OF OSA

•Loss of air to lungs may happen many times per hour •Blood oxygen drops below the 90% level causing the patient to arouse to breath•Arousal causes loss of sleep, daytime sleepiness, decreased production, increased accidents, etc.•May cause medical problems ranging from mild to “life threatening”

WHY DOES THIS MATTER?

• Excessive daytime drowsiness

• Impaired cognitive performance

• Poor quality of life

• Increased risk of MVA (Motor vehicle accidents)

• Adverse cardiovascular outcomes

• Pulmonary hypertension

RISK FACTORS

•Obesity•Age•Sex•Smoking and alcohol consumption•Anatomical predisposing factors•Cardiovascular problems

OBESITY

•Alters upper airway mechanics during sleep1. Increased parapharyngeal fat deposition:

neck circumference: > 17” males

> 16” females

With subsequent:

smaller upper airway

increase the collapsibility of the pharyngeal airway

OBESITY

2. waist circumference

Fat deposition around the abdomen produces

reduced lung volumes (functional residual capacity) which can lead to loss of caudal

traction on the upper airway

low lung volumes are associated with diminished oxygen stores

RISK FACTOR: AGE

0

5

10

15

20

25

30

35

30-39 Yrs 40-49 Yrs 50-60 Yrs

Female

Male

% with AHI > 5

Adapted from Young T et al. N Engl J Med 1993;328.

2006 American Academy of Sleep medicine

SMOKING

0

1

2

3

4

5

Adjusted Odds Ratio for Sleep Apnea (AHI > 15) in Former & Current Smokers vs Nonsmokers

Adapted from Wetter DW et al. Arch Intern Med 1994:154 ©1994 American Medical Association.

Former Current Smokers Smokers

(Adjusted for age, race, sex, BMI)

Odds Ratio

2006 American Academy of Sleep Medicine

CRANIOFACIAL ANATOMY

•Findings in Obstruction:

•Nasal Obstruction

• Long, thick soft palate

•Retrodisplaced Mandible

•Narrowed oropharynx

•Redundant pharyngeal tissues

• Large lingual tonsil

• Large tongue

• Large or flappy Epiglottis

•Retro-displaced hyoid complex

MANAGEMENT OF OSA

MEDICAL RESPONSIBILITY

•Diagnosis and determine presence and severity of an OSD - “Sleep Study”

•Treatment

Dental Responsibilityz Recognize and referz Provide support when requested

DIAGNOSIS OF OSA

DIAGNOSING SNORING / OSA

•Medical history•Sleep history•Extended dental examination including TMJ evaluation•Epworth Sleepiness Scale•Preliminary diagnosis•Referral for medical evaluation (sleep study)

DIAGNOSIS:

• Nocturnal symptoms

1. Snoring

– reflects the critical narrowing

• - prevalence increases with age (60%, 40%)

- the most frequent symptom of OSA

DIAGNOSIS

(nocturnal symptoms continued)

2. Witnessed apneas

3. Nocturnal choking or gasping

- report of waking at night with a choking sensation; passes within a few seconds

4. Insomnia

- sleep maintenance insomnia

- (few have difficulty initiating sleep)

CLINICAL FEATURES

• Daytime symptoms

1. Excessive daytime sleepiness

- severity can be assessed

subjectively = questionnaires

(Epworth Sleepiness Scale)

objectively

MSLT = Multiple Sleep Latency Test

MWT = Maintenance of wakefulness Test

Osler Test

CLINICAL FEATURES

• (daytime symptoms)

2. fatigue

3. memory impairment

4. personality changes

5. morning headaches or nausea

6. depression

EPWORTH SLEEPINESS SCALE

•Likeliness to doze off or fall asleep in certain situations versus to just feeling tired

•Use the following scale to choose the most appropriate number for each situation:

0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing

HOW MUCH AIR SPACE IS PRESENT?•Open fairly wide and slightly protrude your tongue•Grade - I, II, or III(Jamieson AO, Becker PM. Snoring: its evaluation and treatment. Hospital Medicine. March 1996)

Grade I

The tonsillar pillars, soft palate, and uvula can be seen, with at least 5 mm between the tip of the uvula and the base of the tongue

Grade II

Tonsillar pillars and soft palate remain visible, tip of the uvula is obscured by the base of the tongue: part of the free edge of the soft palate is still visible

Grade III

Only the soft palate can be seen

PRELIMINARY DIAGNOSIS

•Snoring only

•Snoring and potential upper airway sleep disorder

•Definite disorder – OSA

DIAGNOSIS

• Combined assessment of clinical features and objective sleep study data.

• The gold standard: overnight polysomnogram

• The Polysomnogram (PSG):

• Provides detailed information on sleep state and

respiratory and gas exchange abnormalities.

PSGSimultaneous recordings of multiple physiological signals during sleep.

Electroencephalogram (EEG)

Electrooculogram (EOG)

Electromyogram (EMG)

Electrocardiogram (ECG)

Oronasal airflow

Chest wall effort

Snore microphone

Oxyhemoglobin saturation

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PSG

• Recurrent episodes of complete or partial collapse of

the upper airway are recorded as apnea or hypopnea

events.

Apnea = complete cessation of airflow

for at least 10 seconds

Hypopnea = 25 – 50% reduction in oronasal airflow associated with desaturation or an arousal from sleep.

PSG

• Sleep apnea severity index:

• AHI = apnea-hypopnea index

= # of apneas and hypopneas / hour of sleep

• Mild: 5 – 15 events/hour of sleep

• Moderate: 15 – 30 event/hour of sleep

• Severe: > 30 events/hour of sleep

APNEA PATTERNS

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Airflow

Respiratoryeffort

POLYSOMNOGRAMPolysomnography in OSA

2006 American Academy of Sleep Medicine

TREATMENT OF OSA

PHYSICIAN TREATMENT OPTIONS

•Behavior modification•CPAP•Surgery•Medications•Oral devices

BEHAVIORAL METHODS

•Weight loss

• Avoid alcohol and sedatives

• Avoid sleep deprivation

• Avoid supine sleep position

• Stop smoking

SLEEP POSITION TRAINING

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CPAP

2006 American Academy of Sleep Medicine

POSITIVE AIRWAY PRESSURE

2006 American Academy of Sleep Medicine

CPAP

• Indications

• Based on AHI

• CMS: AHI >15 events/h or with AHI 5-14 events/h with clinical sequelae (excess daytime sleepiness, cognitive impairment, mood DO, insomnia, cardiovascular dis.)

• Consider CPAP in patients with lower AHI (~5) who have symptoms, perform mission critical work (pilots, bus drivers)

•Mechanism

• Splints open the upper airway to prevent airway collapse

CPAP

•Has been shown to objectively:

• Decrease MVA

• Decrease blood pressure

• Decrease day time sleepiness

CPAP

•Problems:

• Mask discomfort

• Patient acceptance

• Dry mouth, rhinitis, congestion

• Claustrophobia

SURGICAL MANAGEMENT

•Perioperative Issues•High risk in patients with severe symptoms•Associated conditions CVD•Nasal CPAP often required after surgery•Nasal CPAP before surgery improves postoperative course•Risk of pulmonary edema after relief of obstruction

SURGICAL MANAGEMENT

•Nasal Surgery

• Limited efficacy when used alone

• Verse et al 2002 showed 15.8% success rate when used alone in patients with OSA and day-time nasal congestion with snoring

•Adenoidectomy (children)

SURGICAL MANAGEMENT

•Uvulopalatopharyngoplasty• The most commonly performed surgery for OSA• Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months• Friedman et al showed a success rate of 80% at 6 months in carefully selected patients

SURGICAL MANAGEMENT

•Uvulopalatopharyngoplasty

SURGICAL MANAGEMENT

•Tongue Base Procedures

• Lingual Tonsillectomy

• may be useful in patients with hypertrophy, but usually in conjunction with other procedures

SURGICAL MANAGEMENT

•Tongue Base Procedures• Lingualplasty• Chabolle, et al success

rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP• Complication rate of 25% -

bleeding, altered taste, odynophagia, edema

SURGICAL MANAGEMENT

• Lingual Suspension

SURGICAL MANAGEMENT

•Mandibular Procedures

•Genioglossus Advancement

• Rarely performed alone

• Increases rate of efficacy of other procedures

• Transient incisor paresthesia

SURGICAL MANAGEMENT

•Hyoid Myotomy and Suspension

• Advances hyoid bone anteriorly and inferiorly

• Advances epiglottis and base of tongue

• Performed in conjunction with other procedures

• Dysphagia may result

SURGICAL MANAGEMENT

• Maxillary-Mandibular Advancement• Severe disease• Midface, palate, and mandible advanced

anteriorly• Limited by ability to stabilize the

segments and aesthetic facial changes

SURGICAL MANAGEMENT

• Tracheostomy• Primary treatment modality• Temporary treatment while other

surgery is done

SURGICAL MANAGEMENT

•Surgical management provides effective management for OSA

•Can be safely performed in most patients with proper preoperative preparation

•Surgery should be considered for patients unable to utilize nonsurgical management

ORAL DEVICES FOR TREATINGSNORING AND OBSTRUCTIVE SLEEP APNEA

TYPES OF DENTAL DEVICE DESIGNS

FDA has cleared the following types of devices under this regulation:

• Tongue retaining devices

• Mandibular repositioning devices

• Palatal lifting devices

• Tongue Retaining Device

•Mandibular Repositioning Device

Palatal left Device

TREATMENT PROTOCOLS FOR UTILIZING OA THERAPY

1. Assessment by a sleep physician:

2. The sleep physician provides the dentist with a written referral as well as copy of the diagnostic sleep study report.

TREATMENT PROTOCOLS FOR UTILIZING OA THERAPY

3. The dentist assesses if the patient is a candidate for OA therapy, and the patient is advised of the appropriate OA design(s) for that patient

4. An informed consent about the risks and benefits of OA therapy for SRBD is obtained from the patient

TREATMENT PROTOCOLS FOR UTILIZING OA THERAPY

5. OA therapy is initiated by the dentist

6. The patient is referred back to the sleep physician for medical assessment by the sleep physician relative to the OA’s therapy effectiveness.

TREATMENT OBJECTIVES

•“For patients with primary snoring without features of OSA or upper- airway resistance syndrome, the treatment objective is to reduce the snoring to a subjectively acceptable level.”

• “For patients with OSA, the desired outcome of treatment includes the resolution of the clinical signs and symptoms of OSA and the normalization of the apnea-hypopnea index and oxyhemoglobin saturation. ”

TREATMENT OBJECTIVES

Snoring

Oral device

TREATMENT OBJECTIVES

Mild OSA

Behavior managem

ent

Oral device

CPAP

TREATMENT OBJECTIVES

Sever OSA

Surgical managem

ent

CPAP

COMPARISON OF OAS WITH CPAP

• CPAP was more efficacious in reducing the AHI to normal levels as well as controlling snoring in almost all patients,

• OA demonstrated better compliance when compared to CPAP.

TONGUE RETAINING DEVICE(TRD)

Tongue Retaining Device

MECHANISM OF ACTION:

To prevent the tongue from approaching the posterior wall of the pharynx, the patient projects the tip of the tongue into a hollow bulb, thereby creating a suction which retains the tongue in an anterior position

INDICATIONS FOR TRDS

• Edentulous patients

• Patients with potential temporomandibular joint problems

Problems with TRDsz Sore tonguez taste alteration

Kelgauge

MANDIBULAR ADVANCEMENT DEVICES

INDIVIDUAL IMPRESSION BOIL AND BITE

DENTAL CONSIDERATION

• Adequate number of healthy teeth

• The patient should have the ability to protrude the mandible forward and open the jaw widely without significant limitation

Contra indication

• “Moderate to severe TMJ problems

• “Significant bruxism

• Edentulous patients

WarningsUse of device may cause:• Tooth movement or changes

in dental occlusion•Gingival or dental soreness• Pain or soreness of the TMJ•Obstruction of oral breathing• Excessive salivation

PROBLEMS WITH MADS AFTER LONG TERM USE (3 YEARS OR MORE)

•Minor jaw/facial, tooth, muscle pain – 40% •Xerstomia – 30%•Very Satisfied – 82%•Satisfied – 15%•Painless but irreversible change in occlusion - 26%GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and snoring: assessment of an anterior mandibular positioning device. J Am Dent Assoc. 2000;131:765-71.

CONSTRUCTION OF CUSTOM MADE MAD

INTER OCCLUSAL RECORD

• 1. Be able to maintain a lip seal with the OA seated on the dentition, which will foster nasal breathing during sleep.

• 2. Provide the least amount of strain on the masticatory musculature with the use of the OA.

• 3. Focus on the combined approach of mandibular advancement and vertical opening: (a) for optimum effectiveness of the OA

• (b) to lessen the possibility of occlusal changes with the use of an OA.

INTER OCCLUSAL RECORD

• Vertical relation

• Start at between 5 and 7 mm interincisally (Edge to edge)

• Take into consideration Maintain a lip seal

INTER OCCLUSAL RECORD

• Horizontal relation

• Class I (full dentition) Incisors at edge to edge

Advanced 1–4 mm past edge to edge

INTER OCCLUSAL RECORD

• Horizontal relation

• Class II division 1 to >5 mm overjet

• Class II division 2

Advanced up to 5 mm

Advance 2–4 mm beyond edge to edge

INTER OCCLUSAL RECORD

• Horizontal relation

• Class III

• Pseudo class III

Minimal to no advancement Focus on vertical

Minimal advancement (1–3 mm)

Practice CR tomaximum protruded position

Patient closingin the pre-selected protrudedposition

An interocclusalrecording is madeusing the waxmatrix

George Gauge

Adjustment of the device mustbe made depending on device fabricated

PATIENT INSTRUCTIONS FOR ADJUSTMENT(DEPENDS ON DEVICE BUT TYPICAL):

•No adjust for first 3 nights to allow patient to become accustom to device•Protrude device 0.25 mm per night for 3 – 4 nights, stop, check for improvement•Continue until symptoms are relieved or reduced or TMJ symptoms develop

EVALUATION•Following relief of symptoms allow patient to wear device for 2 – 4 weeks•Have patient wear a Pulse Oximetry device and determine success of treatment•Continue adjustments and follow up Pulse Oximetry •Refer to Physician for reevaluation (2nd polysomnography)

PATIENT SHOULD EXPECT

•Lips will be very dry - lip balm

•Difficulty going to sleep for a few nights

•Lots of saliva - on pillow

•Teeth may become sensitive - seek care immediately - usually slight adjustment

PATIENT SHOULD EXPECT

•TMJ discomfort - May be sore for a few minutes during early adjustment, must be relieved by moving mandible posteriorly