dental management of sleep apnea
TRANSCRIPT
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
2006 American Academy of Sleep Medicine
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
2006 American Academy of Sleep Medicine
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
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