Lina Khasawneh

Danah Alghanim
Abd-Alrahman Abu-Shawish
Thikrayat Bani Khaled

Mid

7/1/2021 0

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 Dentist’s Role in the management of Sleep Apnea

Obstructive Sleep Apnea

 Sleep apnea:
 Obstruction of airway during sleeping.
 Clinical manifestations:
o Snoring.
o Inability to breathe (apnea).
 Definition:
Collapse of the pharyngeal walls during sleep causing partial or total
blockage of the airway.
 The obstruction is in the upper airway, causes:
1. Partial blockage (anatomic obstruction) due to the size of the tongue:
 Leads to narrowing of the pharyngeal lumen / pharyngeal space,
which results in snoring.
2. Complete blockage (the airway is totally obstructed):
 Leads To apnea (no breathing).

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 Pattern of snoring in sleep apnea

 The repetitive collapse of the pharyngeal walls during sleep will cause
disturbance in gas exchange which leads to:
1. Oxygen desaturation.
2. Hypercapnia.
3. Sleep fragmentation.
 The pattern will range from partial collapse leading to loud snoring and
episodes of hypopnea, to complete blockage of the airway lasting up to
60 seconds. (This pattern is important to the diagnosis of sleep apnea)
 Once the breathing stops, the patient will wake up gasping for air (due to
oxygen desaturation) then he sleeps again and the cycle repeats itself.
 The patient will not be always aware of this condition, and usually
there is a bed partner who notices it.

Manifestation of this condition during the day

 Daytime sleepiness.
 Tiredness and lack of energy.
 On the long term: Hypertension is due to
 Hypertension. oxygen desaturation and
 Depression. hypercapnia
 Impaired quality of life.

Terminology

 Sleep disordered breathing (SDB).

 Obstructive sleep apnea (OSA).
 Sleep apnea.

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 Central Sleep Apnea & Obstructive Sleep
Apnea
 Difference between Central Sleep Apnea & Obstructive Sleep Apnea
 Central sleep apnea is NOT only related to the obstruction of the airway
(anatomic), but also related to the regulation of sleep from the brain.
 Therefor, the central sleep apnea cannot be managed by the
management modalities we are talking about here (we will only talk
about obstructive sleep apnea).

History of sleep apnea

1966 Clinical entity was identified, they noticed that there was a link
between hypertension and sleep fragmentation.
The only management at that time was only tracheotomy (surgical
procedure where they remove soft palate + uvula) to maintain a
patent airway. (high morbidity & not effective)

1981 Sullivan CPAP (continuous positive air pressure)

 This CPAP changed the management of sleep apnea and
introduce minimally invasive device to treat this condition.
 It is a nasal mask (placed over the nose alone or with the mouth)
which will continue to push air through the nose and oral cavity
to maintain patent airway.
 Since the oxygen flow is better, this will lead to less snoring, and
more energy in the morning.

1986 The healthcare workers pushed the interest of this condition (which
was a health burden) to the US Congress, in order to set up a
specialized cardiopulmonary centers of sleep diseases.

1987 They were able to request grant fund for these centers.

1993 The first epidemiological study was made to study sleep apnea
(Wisconsin sleep study)  landmark for investigation OSA.

1994 Sleep medicine was recognized as a sub speciality.

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 Prevalence

 In 1993, 9% females and 24% males.

 However, due to the increase in the endemic of obesity (mostly, not
always) + change in life style, the prevalence of OSA increased over the
last two decades.
 In 2013, the overall reported prevalence of OSA was 26% (34% among
men and 17% among women).

Health burden of the condition

 Health burden of a disorder is the product of the prevalence and the

proportion of adverse health outcomes that can be attributed to the
disorders.

 This is evaluated by:

*SDB: Sleep-Disordered Breathing

 There are modifying factors that play an important role in this equation.

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 This equation can also be applied on other conditions/diseases not
just sleep apnea
 Like caries, periodontal disease (these act as health burden).
 Our rule should be focused on prevention to reduce number of patients +
incidence of new caries / lesion.
 The burden that we carry as healthcare providers is that we are still doing basic
treatments rather than focusing on early prevention (which should be our main
concern).

1 Direct costs

 Monetary cost of diagnosis and treatment.

 Health cost which includes distress and discomfort associated with
having SDB to the individual sufferer, including unsatisfactory sleep,
low motivation, problems with daytime functioning, quality of life and
relationships.
 Loss of family and society (loss of potential contributions to community
e.g. jobs, volunteer services).
 Snoring can be a deal breaker in interpersonal relationships.
 Morbidity attributable to SDB (hypertension, depression ...).
 Loss of years of life due to SDB.

2 Indirect costs 3 Modifying costs

 SDB exacerbation of  Prevention programs to reduce

comorbidity (the patient already prevalence and progression of
has hypertension for example, SDB (weight loss for example).
but it is exacerbated due to SDB).  Increase in factors that cause or
 Worse prognosis for other worsen SDB (obesity, aging of
disorders due to SDB-related population).
behavioral morbidity (like low  Treatment of SDB that prevents
compliance with therapy for or reduces adverse outcomes.
other disorders, lack of exercise,
obesity … ).
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 Consequences of obstructive sleep apnea (OSA)

It is a chronic condition that the patient has to deal with for his entire life.
1. Daytime sleepiness and tiredness.
2. Sleepiness of the partner who reports loud snoring and witnesses apnea.
3. Serious systemic cardiovascular consequences (system hypertension).
4. Lack of concentration during the day (due to lack of sleep)
 OSA patients are 3 times more likely to have road traffic accidents
(sleep while driving).

Diagnosis of sleep apnea

 Only a small percentage of OSA patients are diagnosed (tip of the

iceberg) and even less percentage are receiving successful treatment of
sleep apnea.
 Clinical patient stereotype: male, middle-aged, sleepy, large neck size.
o The partner witnessed loud snoring + apnea.
o Other comorbidities (hypertension, CVD, diabetes, obesity).

 Around 80% or more of OSA patients are still remain undiagnosed

(base of the iceberg).
 We should raise awareness on these patients + the comorbidities
associated with it.
☂ Note: some people consider snoring as a funny and annoying thing,
that’s why they may consider it normal and do not seek treatment
(remain undiagnosed).

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 Positional therapy

 This is a way to fix snoring by changing the position during sleeping.

 If the patient sleeps on his back he is more likely to snore.
 If he sleeps on his side, the snoring will be reduced.

 There is a device (like a pillow) that will prevent the patient from sleeping on
his back, this will maintain a patent airway.

 The way we diagnose OSA is by Polysomnography

❀ Done in sleep lab in hospitals or at home.
❀ Procedure:
 Done at night.
 The patient should not drink
any stimulants (coffee) or take
any drugs for sleep.
 The technician places the
electrodes on the patient which
measures ECG, EEG, oximetry
and muscle activity (to record
the limb movement) +
voice/video recording.
❀ This device is not specific for sleep apnea, can also be used to diagnose:
 Periodic limb movement disorder.
 Narcolepsy.
❀ A report is made after the procedure, containing O2 saturation,
apnea/hypopnea index (AHI), periodic movements.
❀ Sleep apnea if diagnosed based on number of episodes of apnea per
hour which is the apnea/hypopnea index
 Normal  <5 events per hour
 Mild OSA  5-15
 Moderate OSA  15/30
 Severe OSA  >30

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 Management of OSA

☁ Nasal continuous positive airway pressure (CPAP) or facial mask, is

considered the treatment of choice (the gold standard) for the treatment
of obstructive sleep apnea (minimally invasive).

☁ Function of CPAP:
 Prevent collapse of the pharyngeal wall.
 Maintaining the airway open during
sleep.
 By: maintaining a positive pharyngeal
airway pressure so that it exceeds the
surrounding pressure, thus maintaining
the pharyngeal lumen open.

☁ Despite the high efficacy of this device, the compliance rate is minimal
due to discomfort and also due to social reasons (sleeping is a private
thing).
 The mask may also leave marks on the face, cause dryness of the nose
and eyes due to the continuous air pressure.

Surgical management

☁ Indicated when there is an anatomic obstruction in the area of the soft

palate that can be surgically corrected.
☁ Uvulopalatopharyngoplasty (UPPP) is the most common surgical
procedure for treatment of OSA.

☁ Other surgical procedures used to reduce snoring:

 Tonsillectomy.
 Nasal septal deviation surgical correction.
 Adenoid surgical removal (‫)الزائدة اللحمية‬.
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 UPPP

☁ Involves the surgical removal of the uvula, tonsils and lateral

pharyngoplasty.
☁ It is completed under general anesthesia and associated with significant
postoperative pain and scarring.
☁ Long-term complications: nasal reflux, pharyngeal stenosis, dysphonia,
and velopharyngeal insufficiency (more problems than benefits).
☁ Has low success rate with a meta-analysis showing only 40% success
rate, where success was defined as reduction of the apnea/hypopnea
index by 50% of its preoperative value.

Assessment of the anatomic obstruction

☁ The Mallampati Score: as modified by Friedman is based on

observation of the palate position, where the patient is asked to open
his/her mouth widely without protruding the tongue.

☁ Assess how well you see the structures

when the patient opens his mouth.
 Score (1): we see uvula, lateral
pharyngeal walls, tonsils (tonsillar
pillars), and soft palate.
 Score (2): soft palate + uvula + fauces.
 Score (3): soft palate + base of uvula.
 Score (4): soft palate is invisible
(covered by big sized tongue).

☂ Note: The tonsils may be too large causing obstruction and snoring, and
after tonsillectomy, the condition will be improved.

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 Mandibular advancement devices

☁ Oral appliances appeared as an alternative treatment to CPAP in the

management of snoring and mild to moderate OSA in patients who failed
to adhere to or refused CPAP treatment.
☁ While for sever OSA, the treatment of choice is CPAP.
☁ It is also minimally invasive as CPAP and has high efficacy.
☁ Function:
 Reposition the tongue and mandible forward and downward to reduce
airway collapse
 Widening the lateral aspect of the pharyngeal walls thus improving
the airway patency.
Thornton adjustable positioner (vacuum formed)
on upper and lower teeth
❀ In between there is a hook that allow advancement
of about 1cm (attached to a screw that the patient
moves to controls the amount of advancement).
❀ Worn at night.

Herbst appliance
❀ The screws are present on the lateral part instead of
the anterior part (like Thornton).
❀ Positioning the mandible forward.

Tongue repositioning device

The tongue is positioned forward in the anterior bulge
of the device.

You only take an alginate impression, send it to the lab to fabricate the
device, set it for the patient, periodic reviews
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 Role of a dentist

☁ Our role as dentists lies in the MANAGEMENT of sleep apnea not the
diagnosis.
 The patient will be diagnosed and referred to us with a history of
failure to adhere to CPAP or failure of surgery.

☁ Role of a dentist
 Increase awareness
 Identify the patient profile with sleep apnea by:
o Upper airway assessment (Mallampati score)
 Tongue assessment (size).
o Certain questionnaires;

1 STOP BANG questionnaire

 Each letter indicates a question (S T O P B A N G).
 Patient profile with sleep apnea:

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S - Snores loudly T - Daytime Tiredness
O - Observed sleep apnea, Choking/gasping like breathing
P - High blood Pressure B - High Body mass index
A - Older Age >50 N - Large Neck size
G - Gender: males are more suggestive of having sleep apnea

 This questionnaire is just a quick risk assessment of possibility of sleep

apnea.

2 Epworth Sleepiness Scale

 Chance of dozing from (0) - Less possibility to (3) - more possibility.
 Also measures the chance of dozing while driving in the car.
 The overall score is out of (20).
 Then classified to mild / moderate / severe depending on the score.
 Also for risk assessment only (not diagnosis).

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 3 Berlin questionnaire

 Focuses more on snoring and daytime sleepiness.

 Asks about hypertension as well.
 Divided in categories.
 For risk assessment only as well (not diagnosis).

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 Role of a dentist

❀ Sleep apnea should be diagnosed by a physician, sleep specialist or

pulmonary specialist, and not by dentists.
❀ We only fabricate the device and follow up with it.

☁ Dental problems associated with the use of mandibular advancement

devices:
 May decrease the overjet.
 TMJ symptoms.
 Anterior open-bite.
 On the long-term, the efficacy of these devices reduces and the AHI
score may go back as it was before or even worse.
 Because there will be adaptation of soft tissues to the device.

☁ How is bruxism related to sleep apnea?

 It is suggested that bruxism is a protective mechanism of sleep apnea.
 The patient will grind his teeth in order to move his mandible anteriorly
to maintain patent airway.

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