Sleep Disordered Breathing

and Dentistry

D
National Primary Oral Health
Care Conference
August 9, 2005
Atlanta, Georgia
 Anatomy of Upper Airway
Oral cavity

D
Tongue3
Uvula
Nasal cavity
Pharynx
Genioglossus
Tensor Veli
*Soft tissue
tube
 Physiology of Snoring
Mandible back

D
Tongue back
Partial closure
upper airway
space
Speed airflow
increases
Vibration of uvula
* Other cause???
 Snoring Demographics

D
z 40 - 60% over 50 years snore
z Males twice as likely as females
z Overweight / neck size
z Males 17” or greater
z Females 16” or greater
 Snoring Significance

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

D
Sleep Disorders
Upper Airway Resistant Syndrome
(Tx – Same as OSA)
Obstructive Sleep Apnea (OSA)
 D
Obstructive Sleep Apnea
(OSA)
 Obstructive
Obstructive Sleep
Sleep Apnea
Apnea
z Complete or almost complete reduction in
airflow through the upper airway lasting for

D
more than 10 seconds, resulting in severe
oxygen depletion leading to medical
problems
z Causes - Tongue, obesity, inflammation of
any soft tissues in the upper airway (tonsils,
adenoids), polyps, tumors, etc
z Demographics - 4% of adult middle-aged
males and 2% of females
 Physiology of OSA
Loss of muscle
activity

D
Mandible/
Tongue back
Partial/total
closure airway
Decreased oxygen
to lungs
Blood oxygen
desaturation
 Patients With OSA
z Snore loudly

D
z Stop breathing - snort to start again
z Choke
z Suffer from acid reflux
z Toss and turn
z Wake up frequently
z Daytime sleepines
 Significance of OSA
z Loss of air to lungs may happen many
times per hour

D
z Blood oxygen drops below the 90% level
causing the patient to arouse to breath
z Arousal causes loss of sleep, daytime
sleepiness, decreased production, increased
accidents, etc.
z May cause medical problems ranging from
mild to “life threatening”
 Dental Responsibility
z Recognize and refer

D
z Provide support when requested

Medical Responsibility
z Diagnosis and determine presence and
severity of an UASD - “Sleep Study”
z Determine treatment
z Treat patient or refer for oral device
Physician Treatment Options

D
z Behavior modification
z Surgery
z Medications
z CPAP
z Oral devices
 Behavior Modification

D
z Sleep on side rather than back
z Avoid alcohol late in day and evening (CNS Depressant)
z Minimize use of sedatives
z Weight loss

Long term success poorly documented

 Surgical Procedures
z UPPP - UvuloPalatoPharyngoPlasty

D
z LAUP - Laser-Assisted Uvula-Palatoplasty
z High Frequency Radio Waves to uvula
z Tonsillectomy, adenoidectomy
z Tracheostomy - life saving procedure
z Craniofacial operations - Maxillomandibular
Advancement, Hyoid lift
D
 Maxillomandibular Advancement
(MMA)

D
z The most effective acceptable surgical
treatment of OSA (excluding tracheostomy)
z Success rates of 96%, 97%, 98% and 100%
reported in the literature
z 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.
 Continuous Positive Air
Pressure - CPAP

D
z Most effective of all treatment modalities
z Patient must wear mask while sleeping
z Very noisy equipment, uncomfortable
z Equipment not easily portable
z Compliance poor
D
 D
Medications
z Only for those patient who are not
good candidates for CPAP, Oral
Devices or Surgical Procedures
z Should not be considered by
dentistry
 D
Oral Device
How and What
D
D
 How
How Does
Does An
An Oral
Oral Device
Device Work?
Work?
z Snoring/OSA caused by loss of airway space

D
z Most oral devices advance the mandible
z This pulls the genioglossus forward
z This pulls the tongue forward
z Upper airway space is regained
z Snoring/OSA diminished or eliminated
z Others simply keep the tongue protruded
 D
All Dental Patients Should be
Evaluated for a Potential Sleep
Disorder
 Diagnosing Snoring / OSA
z Medical history

D
z Sleep history
z Extended dental examination including TMJ
evaluation
z Epworth Sleepiness Scale
z Preliminary diagnosis
z Referral for medical evaluation (sleep study)
 Quality of Sleep Questions
z Snore loudly

D
z Stop breathing - snort to start again
z Choke
z Suffer from acid reflux
z Toss and turn during sleep
z Wake up frequently
z Have daytime sleepiness
 Questions I’ll Ask
1. Weight Compared to Year Ago?

D
2. Ever Treated for Nasal Congestion
3. Neck Circumference
4. Alcohol/Sedatives- How Often?
5. Tired/Sleepy During the Day?
6. Sleep Position - Back, sides, stomach
 Questions I’ll Ask
6. Frequency and loudness of snoring

D
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?
 How much air space is present?

D
z Open fairly wide and slightly protrude your tongue
z Grade - I, II, or III
(Jamieson AO, Becker PM. Snoring: its
evaluation and treatment. Hospital Medicine.
March 1996)
 Grade I

D
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

D
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

D
Only the soft palate can be seen
 Epworth Sleepiness Scale
z Likeliness to doze off or fall asleep in certain

D
situations versus to just feeling tired
z 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
 Preliminary Diagnosis

D
z Snoring only
z Snoring and potential upper airway
sleep disorder
z Definite disorder – OSA or UARS
 D
Oral Devices for Treating
Snoring and
Obstructive Sleep Apnea
 Oral
Oral Devices
Devices Indications
Indications
Recommended for snoring and mild

D
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
 Problems with MADs after long term
use (3 years or more)

D
z Minor jaw/facial, tooth, muscle pain – 40%
z Xerstomia – 30%
z Very Satisfied – 82%
z Satisfied – 15%
z 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.
 CLINICAL IMPLICATIONS
z Patients with mild-to-moderate OSA

D
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.
 D
Device Treatment Options
Tongue Retaining Device (TRD)
Mandibular Advancement Device (MAD)
 D
Tongue Retaining Device
(TRD)
Laboratory fee - $150
 Indications for TRDs
z Edentulous patients

D
z Patients with potential
temporomandibular joint problems
Problems with TRDs
z Sore tongue
z Tongue elongation
Tongue Retaining Device

D
Kelgauge

D
D
D
D
D
 TRD Findings
z Altered the timing of the inspiratory
genioglossus (GG) activity and the onset of

D
inspiration effort
z Oxygen desaturation index dropped to fewer
than 10 events/ h in 75% of patients
z Significantly improved the blood oxygen
saturation level in infants
z Helped patients with mild to moderate OSA;
however, patients with more severe OSA may
also be treated effectively
 D
Mandibular Advancement
Devices
z Fixed - $100 - 500
z Adjustable - $300 - 800
 D
Fabrication of an “Adjustable”
Laboratory Fabricated Device
 D
Practice CR to
maximum protruded
position
D
D
D
Patient closing
in the
pre-selected

D
protruded
position
 An interocclusal
recording is made
using the wax

D
matrix
D
D
D
D
 Adjustment of the
device must

D
be made
depending on device
fabricated
 Patient instructions for adjustment
(depends on device but typical):

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

D
to wear device for 2 – 4 weeks
z Have patient wear a Pulse Oximetry device
and determine success of treatment
z Continue adjustments and followup Pulse
Oximetry or
z Refer to Physician for reevaluation
(2nd polysomnography)
D
 Patient Should Expect
z Lips will be very dry - lip balm

D
z Difficulty going to sleep for a few nights
z Lots of saliva - on pillow
z Teeth may become sensitive - seek care
immediately - usually slight adjustment
 Patient Should Expect
z For approximately 20 minutes upon

D
awakening teeth will not close together -
don’t force closure - no treatment
z TMJ discomfort - May be sore for a few
minutes during early adjustment, must be
relieved by moving mandible posteriorly
 Consent Form Before Treating

D
z Device for treatment of snoring and/or OSA
z Cease wearing and return to dentist immediately
if any problems develop
z Device may only be partially successful
z May cause existing dental restorations to
loosened or fail
z Device may increase severity of an existing OSA
 Is Insurance Coverage
Available? Yes and No

D
z Yes - medical insurance coverage is possible
for treatment of a diagnosed sleep apnea
condition. Very hard to collect
z No - medical insurance coverage for a
snoring only problem
z No - dental insurance coverage for either
 Treating OSA with Oral Devices

D
MD exam $100 – 500
Initial Sleep Study $900 – 1800
Device and Follow-up $800 – 2000
Pulse Oximetry $35 – 200
Repeat Sleep Study $900 – 1800
Total $2735 – 6300
 D
Sleep Disorders in Infants
and Children
Prevalence in Infants and Children
z 3 – 12% snore

D
z 1 – 10% have OSA
When do problems occur
z Snoring – 22.7 months
z Apnea – 34.7 months
Symptoms - 352 OSA children exhibited :
z Chronic mouth breathing (84%)

D
z Otitis media (middle ear infection) (64%)
z Sinusitis (56%)
z Sore throat (51%)
z Choking (47%)
z Daytime drowsiness (42%)
z Less observed symptoms included poor school
performance, enuresis (bed wetting), poor
appetite and/or weight gain, dysphagia, and
vomiting.
 What Do Studies Show?
z 7% of the children were habitual snorers and

D
exhibited a higher prevalence of difficulty in
breathing, observed apneas, restless sleep, and
nocturnal enuresis than non-snorers
z Subjects were more likely to fall asleep while
watching television and in public places and
were hyperactive
z The presence of asthma and hay fever
increased the likelihood of habitual snoring

D
with exposure to cigarette smoking at home
z Primary snoring was corrected with
adenotonsillectomy resulting in weight gain
and a restoration of normal growth
z 26% of children with mild symptoms of
Attention-Deficit/Hyperactivity Disorder
(ADHD) also demonstrate OSA as observed
during polysomnography testing
z Almost 25% of OSA children had clinically
significant behavioral sleep problems such as
sleep walking and nightmares as well as a greater

D
incidence of daytime externalizing behavior
problems
z Children 11 to14 years of age who were
diagnosed as being sleep deficient exhibited
lowered self-esteem, significantly lower grades
and higher levels of depressive symptoms than
those students registering more normal sleep
duration
z The early onset of alcohol, marijuana or illicit
drug use by the adolescent as well as an early
onset of cigarette use by the age of 12 to 14

D
could be significantly predicted by the
mother’s ratings of their children’s sleep
problems at ages 3 to 5 years
z Children with sleep disorders and attention
deficit hyperactivity disorder had a verbal IQ
(intelligence quotient) up to 20 points lower
than control subjects
z Children with lower academic
performance in middle school were more

D
likely to have snored in early childhood
and have required tonsillectomy and
adenoidectomy
z Persistent sleep disturbance is likely to
adversely affect cognition, mood, behavior
and family function
z Habitual snoring was significantly
associated with lowered academic

D
performances in mathematics, science and
spelling in third grade children
z Infantile OSAS does occur in infants due
to hypertrophic adenoids and tonsils and
that among other things these infants
failed to gain weight
 Recognition
z Of all observations made by parents, that

D
of “snoring every night”, is the most
significant factor in predicting OSA
z Children with sleep breathing disorders
had the dolico facial pattern
(disproportionately long face)
z Migraine headaches may be indicative of
sleep disturbances
 Risk Factors for sleep apnea
in children include:

D
z Obesity
z African-American race
z Sinus problems
z Persistent wheezing
 Guideline for Diagnosis of
OSAS
1. All children should be screened for

D
snoring
2. Complex high-risk patients should be
referred to a specialist
3. Patients with cardiorespiratory failure
cannot await elective evaluation
4. Diagnostic evaluation is useful in
discriminating between primary snoring
and OSAS, the gold standard being
polysomnography
 Guideline for Diagnosis of
OSAS
5. Adenotonsillectomy is the first line of

D
treatment for most children, and
continuous positive airway pressure is an
option for those who are not candidates
for surgery or do not respond to surgery
6. Patients should be reevaluated
postoperatively to determine whether
additional treatment is required
 Treatment
z Children with OSA have marked increases in
healthcare-related costs

D
z If prompt diagnosis and management are not
implemented some of these complications may not
be completely reversible, resulting in long-lasting
consequences
z Adenotonsillectomy is the treatment of choice for
most children and continuous positive airway
pressure may be an option for those patients who are
not a candidate for surgery or who do not respond to
surgery
 Treatment
z Caregivers detected a long-term improvement in
quality of life following adenotonsillectomy for

D
OSA although the results were not uniform
z Decreasing nasal congestion associated with
allergic rhinitis can improve sleep in these
patients and lead to improved daytime quality of
life
z CPAP can be effectively used in children less
than 2 years of age
 Treatment
z Children with primary snoring were unlikely to
develop polysomnography-confirmed OSA and

D
therefore delayed treatment was safe
z For patients with residual problems following
adenotonsillectomy, collaboration with
orthodontists to improve craniofacial risk factors
should be considered
 Summary
z Failure to diagnose and treat these patients can

D
result in serious but usually reversible problems
which may include impaired growth,
neurocognitive and behavioral dysfunction and
cardiorespiratory failure
z Identifying these patients may be difficult
because they may not exhibit signs or symptoms
while awake
Academy of Dental Sleep Medicine
One Westbrook Corporate Center

D
Suite 920
Westchester, IL 60154
(708) 273-9335
Annual Membership $295
Quarterly - “ADSM Report”
Quarterly – “Sleep and Breathing”
www. dentalsleepmed.org