4/14/2015

1

Point: Non-surgical Management

of Obstructive Sleep Apnea

by

Alan A. Lowe DMD, PhD, FRCD(C)

AAO 115th Annual Session May 18, 2015

UBC Dentistry Sleep Apnea Team

Alan A. Lowe Professor

Fernanda Almeida Assistant Professor

Ben Pliska Assistant Professor

Hui Chen Clinical Assistant Professor

Bing-shuang Zou Visiting Clinical Associate Professor

Kentaro Okuno Visiting Clinical Lecturer

Mary Wong Programmer/Data Base Manager

Sandra Harrison Clinical Coordinator

Sundus Hussain Clinical Trials Manager

Sleep Disordered Breathing

Snoring Upper Airway Obstructive

Resistance Sleep Apnea

Syndrome

Mild Mild Mild

Moderate Moderate Moderate

Severe Severe Severe

+/- Symptoms ++/- Symptoms ++++/- Symptoms

+/-Health Implications ++/-Health Implications +++++Health Implications

Definitions Apnea

Cessation of airflow > 10 sec whereby the drop in airflow amplitude is > 90% of the baseline

Hypopnea

Breathing that is shallower or slower than normal by

> 30% for at least 10 seconds

Desaturation

A drop of >4% SpO2. A value below 90% is considered abnormal

Severity is classified by the Apnea Hypopnea Index (AHI)

0-5 events/hr Normal

5-15 Mild

15-30 Moderate

>30 Severe

Management of

Sleep Disordered Breathing

1) Avoidance of Risk Factors

2) Nasal Continuous Positive Airway Pressure (nCPAP)

3) Oral Appliances – More than 130 options

4) Surgery

AADSM Treatment Protocol June 2013

Physician medical assessment must be made before OA therapy

Diagnostic sleep study is interpreted by a medical sleep specialist

After initial calibration of a custom-made OA, dentist may obtain

objective data to verify improvement

After final calibration, dentist refers OA patient back to physician for

medical evaluation and assessment of OA outcomes

Patients diagnosed with primary snoring may be treated without

objective follow-up data

Knowledge of various appliances is recommended

Dentists have responsibility to routinely pursue additional education in

the field and to comply with applicable regulations

4/14/2015

2

AADSM/AASM Guidelines Feb 2015

RECOMMENDTIONS

42a When a sleep physician prescribes an OA for adult OSA,

qualified dentist to use a custom titratable OA (G)

42b Sleep physicians to prescribe OAs for adult OSAs who are

intolerant of CPAP or prefer an alternate therapy (S)

42c Qualified dentists oversee dental-related side effects or

occlusal changes to reduce their incidence (G)

42d Sleep physicians conduct follow-up OA sleep test for

adult OSAs to confirm efficacy (G)

42e Both sleep physicians and qualified dentists request adult

OSA OA patients to return for periodic office visits (G)

OA Modes of Action OA Modes of Action

Mandibular Repositioners Preformed “Boil and Bite”

Laboratory Manufactured

Single jaw position vs titratable

Tongue Retainers

Preformed

Laboratory Manufactured

Mandibular Repositioner Herbst

SnoreGuard Narval

4/14/2015

3

SomnoDent TAP

Klearway Tongue Retaining Device

Titration Aids

Patient or bed partner titration goals

Oximetry at home

Portable monitoring at home

Polysomnogram attended in the laboratory

OA Patient Titration Goals

• The patient feels more rested during the day and experiences deep

uninterrupted sleep.

• A resolution of morning headaches has occurred.

• An inability to tolerate any further advancement.

• A change in dream patterns may indicate REM catch up.

• A history from the bed partner (bed side tape recorder) that the

snoring intensity and/or frequency has changed. Usually a Snore

Score of 2 or 3 suggests that the airway is open. However, be

cautious of silent apneics until after the follow up analysis is

completed.

4/14/2015

4

Why are Oral Appliances

Effective?

Airway Size

Tongue and Jaw Muscle Activity

Mandibular Posture and Bruxism

Before Insertion After Insertion

Before Insertion After Insertion Before Insertion After Insertion

VERTICAL MANDIBULAR POSTURE BEFORE

DURING AND AFTER APNEIC EVENTS

During NREM

Opening was larger in latter half of apneic event than

before and at onset

Opening progressively increased during apneic event

Opening decreased at end of apneic event

During REM

No significant change

Oral appliances may be effective since they stabilize

mandibular posture during apneic events

TIME IN EACH RANGE DURING NREM AND REM

FOR OSA PATIENTS AND CONTROLS

During NREM

Open 2 to 2.5 less in OSA

Open 5 to 10 and more greater in OSA

During REM

Open 0 to 2.5 less in OSA

% total time open more than 5 is larger in OSA

patients (69.3) than in controls (11.1) during

NREM sleep

4/14/2015

5

Criteria Mild Moderate

Subjective 36% 20%

Clinical 82% 50%

RJM 54% 40%

Bruxism (2 of 3) 55% 40%

Overall 48%

Control 8%

L24

OA and Sleep Bruxism

An adjustable OA reduced episodes + number of bursts/hr and SB episodes with tooth-grinding noises

25% protrusion reduced SB events by 39%

75% protrusion reduced SB events by 47%

An OA may be an alternative for SB and snoring/OSA patients

Landy-Schonbeck et al, Int J Prosthodont 2009; 22:251-259

Snoring and Occlusal Splints

Maxillary occlusal splint worn for 7 nights in subjects with snoring and OSA

AHI increased 50% in half of the patients

Snoring time increased by 40%

Significant risk of aggravation of respiratory disturbances

Potential reduction of intraoral and tongue space as well as an increase in the vertical dimension

Gagnon et al, Int J Posthodont 2004;17:447-53

MINIMUM SaO2

70

75

80

85

90

95

CPAP OA

Baseline

Outcome

*p<0.001 *p<0.01

APNEA + HYPOPNEA INDEX

0

10

20

30

40

50

CPAP OA

Baseline

Outcome

*p<0.001 *p<0.001

EPWORTH SLEEPINESS SCALE

0

2

4

6

8

10

12

14

16

CPAP OA

Baseline

Outcome

*p<0.001 *p<0.002

4/14/2015

6

QUALITY OF LIFE

0

1

2

3

4

5

6

7

CPAP OA

Baseline Outcome

*p<0.001 *p<0.001 SAQLI

Total

Score

Systolic (SBP) & Diastolic (DBP)

20

40

60

80

100

120

140

160

180

16

:00

17

:00

18

:00

19

:00

20

:00

21

:00

22

:00

23

:00

0:0

0

1:0

0

2:0

0

3:0

0

4:0

0

5:0

0

6:0

0

7:0

0

8:0

0

9:0

0

10

:00

11

:00

12

:00

mm

Hg

◆: Pre-SBP. ◆ :Post-SBP, ▲: Pre-DBP, ▲ :Post-DBP

Carotid Artery Calcification (CAC) Shapes Carotid Artery Calcification (CAC) Shapes

Ovoid Linear Irregular Japanese 66Y F

BMI: 27.4

AHI: 20

Shape: ovoid

Visualization: fair

Case 1 Ovoid

Case 1 Ovoid

Case 2 Linear +

Osteophyte

Japanese 53Y M

BMI: 24.7

AHI: 25.1

Shape: linear

Visualization: good

epiglottis

thyroid cartilage

osteophyte

Japanese Data Canadian Data

Total Calcification NO

calcification Total Calcification

NO

calcification

N 1012 96 916 508 34 474

Sex (M/F) 821/191 72/24 749/167 392/116 26/8 366/108

Age 50.5±14.5 57.6±12.6** 49.8±14.5** 48.5±11.2 50.8±12.9 48.33±11.1

BMI 26.0±4.7 25.4±3.7 26.0±4.7 29.5±5.5 26.9±3.2* 29.7±5.6*

AHI 27.4±23.6 28.6±21.6 27.3±23.8 29.8±21.6 25.0±18.8 30.1±21.7

* Statistical significance (p<0.01) ** Statistical significance (p<0.000)

Prevalence of

calcification

6.7%

Prevalence of

calcification

9.5%

4/14/2015

7

CAC Follow Up CAC Follow Up

After identifying a possible CAC on a lateral headfilm or on a panorex, it would be appropriate to refer the patient to a radiologist experienced in the field to confirm the finding.

Further tests coordinated by the patient’s physician may include a CT scan and/or a color Doppler ultrasound image.

Sample of a Carotid Artery Doppler Image Sample of a Carotid Artery Doppler Image

Occlusal Changes After Five Years of OA Use

Favorable Change

Correction of Class ll molar

Correction of Class ll cuspid

Reduced OJ or OB

Reduced palatal impingement

Reduced lower incisor crowding

Unfavorable Change

Edge to edge incisors

Reverse OJ or OB

Vertical open bite

Reduced interarch contacts

Posterior cross bite

No Change 70 OSA

Patients

Favorable

29 (41.4%)

Unfavorable

31 (44.3%)

Small

13

Intermediate

13

Large

3

Large

8

Intermediate

15

Small

8

Change

60 (85.7%)

No Change

10 (14.3%)

Skeletal Type and Outcomes

Class I Class II/1 Class II/2 Class III

No Change 12.5% 10% 20% 50%

Favorable 25.0% 90% 80% -

Unfavorable 62.5% - - 50%

4/14/2015

8

Four Years of Profile Lite Nasal Mask

(Respironics)

SNA SNB

SNPg Convexity ANB

SNU1

Tsuda, H., Almeida, F.R., Tsuda, T., Moritsuchi, Y. and Lowe, A.A. “Craniofacial Changes after Two Years of Nasal

Continuous Positive Airway Pressure Use in Patients with Obstructive Sleep Apnea”, Chest, 138:870-874, (2010).

Superimposition on the SN line of a typical OSA subject

at baseline and after 35M of nCPCP wear

____ baseline

……. follow-up

Breeze SleepGear –

Puritan Bennett

Mirage Swift -

ResMed

NASAL PILLOW ALTERNATIVES

Profile Lite Nasal

Mask- Respironics

4/14/2015

9

Date Questionnaire Min O2 (%) RDI/hr AHI/hr ODI/hr

Pretreatment 2008/2/29 69 89 8 5 2.5

Posttreatment (with Klearway) 2008/9/20 34 94 2.4 0 0

Posttreatment (without Klearway) 2008/9/30 93 3.2 2.6 1

Portable Monitor (Watch-Pat)

Some OSA Guidelines for Orthodontists

Don’t hesitate to refer to adult/pediatric sleep specialists

Avoid treatment without a written referral from a physician

Be cautious in patients with previous orthodontic therapy

Use recognized appliances with RCT research

Both case and appliance selection are very important

Be aware of silent apneics and post titration follow up

Don’t over treat post OA or nCPAP occlusal changes

Not all Class IIs have OSA / not all OSAs are Class II

Be engaged in this rapidly changing and exciting field

American Academy of Dental

Sleep Medicine

2510 N Frontage Road,

Darien, Illinois 60561

Phone: (630) 737-9705 Fax: (630) 737-9790

Web Site: www.aadsm.org

The Web site has information about the AADSM, a geographic

listing of members, certification status and Web site links.

Alan A. Lowe, DMD, PhD, FRCD(C)

Professor and Chair, Division of Orthodontics

Director, Frontier Clinical Research Center

Department of Oral Health Sciences

Faculty of Dentistry, The University of British Columbia

2199 Wesbrook Mall, Vancouver, B.C. V6T 1Z3

Phone: (604) 822-3414 Fax: (604) 822-3562

E-mail: alowe@dentistry.ubc.ca

http://www.Klearway.com