Sleep Disordered Breathing and Dentistry

1. Sleep Disordered Breathingand Dentistry National Primary Oral Health Care ConferenceAugust 9, 2005Atlanta, Georgia

2. Anatomy of Upper Airway Oral cavity Tongue3 Uvula Nasal cavity Pharynx Genioglossus Tensor Veli *Soft tissue tube

3. Physiology of Snoring Mandible back Tongue back Partial closure upper airway space Speed airflow increases Vibration of uvula * Other cause???

4. Snoring Demographics • 40 - 60% over 50 years snore • Males twice as likely as females • Overweight / neck size • Males 17” or greater • Females 16” or greater

5. Snoring Significance • Snorers awaken their partners and occasionally themselves by the loudness of their snoring resulting in loss of sleep (to be discussed later) • 10 - 20 % have a Severe Upper Airway Sleep Disorder!

6. Severe Upper Airway Sleep Disorders Upper Airway Resistant Syndrome (Tx – Same as OSA) Obstructive Sleep Apnea (OSA)

7. Obstructive Sleep Apnea(OSA)

8. Obstructive Sleep Apnea • Complete or almost complete reduction in airflow through the upper airway lasting for more than 10 seconds, resulting in severe oxygen depletion leading to medical problems • Causes - Tongue, obesity, inflammation of any soft tissues in the upper airway (tonsils, adenoids), polyps, tumors, etc • Demographics - 4% of adult middle-aged males and 2% of females

9. Physiology of OSA Loss of muscle activity Mandible/ Tongue back Partial/total closure airway Decreased oxygen to lungs Blood oxygen desaturation

10. Patients With OSA • Snore loudly • Stop breathing - snort to start again • Choke • Suffer from acid reflux • Toss and turn • Wake up frequently • Daytime sleepines

11. 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”

12. Dental Responsibility Medical Responsibility • Recognize and refer • Provide support when requested • Diagnosis and determine presence and severity of an UASD - “Sleep Study” • Determine treatment • Treat patient or refer for oral device

13. Physician Treatment Options • Behavior modification • Surgery • Medications • CPAP • Oral devices

14. Behavior Modification • Sleep on side rather than back • Avoid alcohol late in day and evening (CNS Depressant) • Minimize use of sedatives • Weight loss Long term success poorly documented

15. Surgical Procedures • UPPP - UvuloPalatoPharyngoPlasty • LAUP - Laser-Assisted Uvula-Palatoplasty • High Frequency Radio Waves to uvula • Tonsillectomy, adenoidectomy • Tracheostomy - life saving procedure • Craniofacial operations - Maxillomandibular Advancement, Hyoid lift

17. Maxillomandibular Advancement (MMA) • The most effective acceptable surgical treatment of OSA (excluding tracheostomy) • Success rates of 96%, 97%, 98% and 100% reported in the literature • Caution – Reports of devitalization of teeth cause by surgical procedures Prinsell JR. Maxillomandibular advancement (MMA) in a Site-Specific treatment approach for obstructive sleep apnea: A surgical approach. Sleep Breath. 2000;4:147-54.

18. Continuous Positive Air Pressure - CPAP • Most effective of all treatment modalities • Patient must wear mask while sleeping • Very noisy equipment, uncomfortable • Equipment not easily portable • Compliance poor

20. Medications • Only for those patient who are not good candidates for CPAP, Oral Devices or Surgical Procedures • Should not be considered by dentistry

21. Oral DeviceHow and What

24. How Does An Oral Device Work? • Snoring/OSA caused by loss of airway space • Most oral devices advance the mandible • This pulls the genioglossus forward • This pulls the tongue forward • Upper airway space is regained • Snoring/OSA diminished or eliminated • Others simply keep the tongue protruded

25. All Dental Patients Should be Evaluated for a Potential Sleep Disorder

26. Diagnosing Snoring / OSA • Medical history • Sleep history • Extended dental examination including TMJ evaluation • Epworth Sleepiness Scale • Preliminary diagnosis • Referral for medical evaluation (sleep study)

27. Quality of Sleep Questions • Snore loudly • Stop breathing - snort to start again • Choke • Suffer from acid reflux • Toss and turn during sleep • Wake up frequently • Have daytime sleepiness

28. Weight Compared to Year Ago?2. Ever Treated for Nasal Congestion 3. Neck Circumference4. Alcohol/Sedatives- How Often?5. Tired/Sleepy During the Day?6. Sleep Position - Back, sides, stomach Questions I’ll Ask

29. Questions I’ll Ask 6. Frequency and loudness of snoring 7. Previous Sleep Studies or Past Treatment for Snore Problems? 8. Do You Ever Awaken Gasping for Air? 9. Ever Been Told That You Stop Breathing While You Sleep?

30. 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)

31. 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

32. 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

33. Grade III Only the soft palate can be seen

34. 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

35. Preliminary Diagnosis • Snoring only • Snoring and potential upper airway sleep disorder • Definite disorder – OSA or UARS

36. Oral Devices for TreatingSnoring and Obstructive Sleep Apnea

37. Oral Devices Indications Recommended for snoring and mild to moderate sleep apnea if CPAP unsuccessful. • Practice parameters for the treatment of snoring and obstructive sleep apnea with oral devices. An American Sleep Disorders Association Report. Sleep. 1995;18(6):511-13

38. 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.

39. CLINICAL IMPLICATIONS • Patients with mild-to-moderate OSA who receive a two-piece, adjustable MAD should be informed that 50 percent of patients quit using the device in a three-year period and some will experience shifts in their occlusion.

40. Device Treatment Options Tongue Retaining Device (TRD) Mandibular Advancement Device (MAD)

41. Tongue Retaining Device(TRD) Laboratory fee - $150

42. Indications for TRDs • Edentulous patients • Patients with potential temporomandibular joint problems Problems with TRDs • Sore tongue • Tongue elongation

43. Tongue Retaining Device

44. Kelgauge

49. TRD Findings • Altered the timing of the inspiratory genioglossus (GG) activity and the onset of inspiration effort • Oxygen desaturation index dropped to fewer than 10 events/ h in 75% of patients • Significantly improved the blood oxygen saturation level in infants • Helped patients with mild to moderate OSA; however, patients with more severe OSA may also be treated effectively

50. Mandibular Advancement Devices • Fixed - $100 - 500 • Adjustable - $300 - 800