Transcript snoring & sleep apnea diagnosis & treatment

Sleep Disordered Breathing
and Dentistry
National Primary Oral Health
Care Conference
August 9, 2005
Atlanta, Georgia
Anatomy of Upper Airway
Oral cavity
Tongue3
Uvula
Nasal cavity
Pharynx
Genioglossus
Tensor Veli
*Soft tissue
tube
Physiology of Snoring
Mandible back
Tongue back
Partial closure
upper airway
space
Speed airflow
increases
Vibration of uvula
* Other cause???
Snoring Demographics
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40 - 60% over 50 years snore
Males twice as likely as females
Overweight / neck size
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Males 17” or greater
Females 16” or greater
Snoring Significance
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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!
Severe Upper Airway
Sleep Disorders
Upper Airway Resistant Syndrome
(Tx – Same as OSA)
Obstructive Sleep Apnea (OSA)
Obstructive Sleep Apnea
(OSA)
Obstructive Sleep Apnea
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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
Physiology of OSA
Loss of muscle
activity
Mandible/
Tongue back
Partial/total
closure airway
Decreased oxygen
to lungs
Blood oxygen
desaturation
Patients With OSA
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Snore loudly
Stop breathing - snort to start again
Choke
Suffer from acid reflux
Toss and turn
Wake up frequently
Daytime sleepines
Significance of OSA
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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”
Dental Responsibility
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Recognize and refer
Provide support when requested
Medical Responsibility
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Diagnosis and determine presence and
severity of an UASD - “Sleep Study”
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Determine treatment
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Treat patient or refer for oral device
Physician Treatment Options
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Behavior modification
Surgery
Medications
CPAP
Oral devices
Behavior Modification
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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
Surgical Procedures
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UPPP - UvuloPalatoPharyngoPlasty
LAUP - Laser-Assisted UvulaPalatoplasty
High Frequency Radio Waves to uvula
Tonsillectomy, adenoidectomy
Tracheostomy - life saving procedure
Craniofacial operations Maxillomandibular Advancement,
Hyoid lift
Maxillomandibular Advancement
(MMA)
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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 SiteSpecific treatment approach for obstructive sleep apnea: A surgical
approach. Sleep Breath. 2000;4:147-54.
Continuous Positive Air
Pressure - CPAP
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Most effective of all treatment
modalities
Patient must wear mask while sleeping
Very noisy equipment, uncomfortable
Equipment not easily portable
Compliance poor
Medications
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Only for those patient who are not
good candidates for CPAP, Oral
Devices or Surgical Procedures
Should not be considered by
dentistry
Oral Device
How and What
How Does An Oral Device Work?
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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
All Dental Patients Should be
Evaluated for a Potential Sleep
Disorder
Diagnosing Snoring / OSA
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Medical history
Sleep history
Extended dental examination including
TMJ evaluation
Epworth Sleepiness Scale
Preliminary diagnosis
Referral for medical evaluation (sleep
study)
Quality of Sleep Questions
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Snore loudly
Stop breathing - snort to start again
Choke
Suffer from acid reflux
Toss and turn during sleep
Wake up frequently
Have daytime sleepiness
Questions I’ll Ask
1. Weight Compared to Year Ago?
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
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?
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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
Epworth Sleepiness Scale
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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
Preliminary Diagnosis
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Snoring only
Snoring and potential upper airway
sleep disorder
Definite disorder – OSA or UARS
Oral Devices for Treating
Snoring and
Obstructive Sleep Apnea
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
Problems with MADs after long term
use (3 years or more)
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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.
CLINICAL IMPLICATIONS
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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.
Device Treatment Options
Tongue Retaining Device (TRD)
Mandibular Advancement Device (MAD)
Tongue Retaining Device
(TRD)
Laboratory fee - $150
Indications for TRDs
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Edentulous patients
Patients with potential
temporomandibular joint problems
Problems with TRDs
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Sore tongue
Tongue elongation
Tongue Retaining Device
Kelgauge
TRD Findings
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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
Mandibular Advancement
Devices
z Fixed - $100 - 500
z Adjustable - $300 - 800
Fabrication of an “Adjustable”
Laboratory Fabricated Device
Practice CR to
maximum protruded
position
Patient closing
in the
pre-selected
protruded
position
An interocclusal
recording is made
using the wax
matrix
Adjustment of the
device must
be made
depending on device
fabricated
Patient instructions for adjustment
(depends on device but typical):
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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
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
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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 followup Pulse
Oximetry or
Refer to Physician for reevaluation
(2nd polysomnography)
Patient Should Expect
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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
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For approximately 20 minutes upon
awakening teeth will not close together don’t force closure - no treatment
TMJ discomfort - May be sore for a few
minutes during early adjustment, must be
relieved by moving mandible posteriorly
Consent Form Before Treating
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Device for treatment of snoring and/or OSA
Cease wearing and return to dentist
immediately if any problems develop
Device may only be partially successful
May cause existing dental restorations to
loosened or fail
Device may increase severity of an existing
OSA
Is Insurance Coverage
Available? Yes and No
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Yes - medical insurance coverage is
possible for treatment of a diagnosed sleep
apnea condition. Very hard to collect
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No - medical insurance coverage for a
snoring only problem
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No - dental insurance coverage for either
Treating OSA with Oral Devices
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
Sleep Disorders in Infants
and Children
Prevalence in Infants and Children
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3 – 12% snore
1 – 10% have OSA
When do problems occur
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Snoring – 22.7 months
Apnea – 34.7 months
Symptoms - 352 OSA children exhibited :
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Chronic mouth breathing (84%)
Otitis media (middle ear infection) (64%)
Sinusitis (56%)
Sore throat (51%)
Choking (47%)
Daytime drowsiness (42%)
Less observed symptoms included poor school
performance, enuresis (bed wetting), poor
appetite and/or weight gain, dysphagia, and
vomiting.
What Do Studies Show?
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7% of the children were habitual snorers and
exhibited a higher prevalence of difficulty in
breathing, observed apneas, restless sleep, and
nocturnal enuresis than non-snorers
Subjects were more likely to fall asleep while
watching television and in public places and
were hyperactive
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The presence of asthma and hay fever
increased the likelihood of habitual snoring
with exposure to cigarette smoking at home
Primary snoring was corrected with
adenotonsillectomy resulting in weight gain
and a restoration of normal growth
26% of children with mild symptoms of
Attention-Deficit/Hyperactivity Disorder
(ADHD) also demonstrate OSA as observed
during polysomnography testing
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Almost 25% of OSA children had clinically
significant behavioral sleep problems such as
sleep walking and nightmares as well as a
greater incidence of daytime externalizing
behavior problems
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
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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
could be significantly predicted by the mother’s
ratings of their children’s sleep problems at
ages 3 to 5 years
Children with sleep disorders and attention
deficit hyperactivity disorder had a verbal IQ
(intelligence quotient) up to 20 points lower
than control subjects
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Children with lower academic
performance in middle school were more
likely to have snored in early childhood
and have required tonsillectomy and
adenoidectomy
Persistent sleep disturbance is likely to
adversely affect cognition, mood, behavior
and family function
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Habitual snoring was significantly
associated with lowered academic
performances in mathematics, science and
spelling in third grade children
Infantile OSAS does occur in infants due
to hypertrophic adenoids and tonsils and
that among other things these infants
failed to gain weight
Recognition
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Of all observations made by parents, that
of “snoring every night”, is the most
significant factor in predicting OSA
Children with sleep breathing disorders
had the dolico facial pattern
(disproportionately long face)
Migraine headaches may be indicative of
sleep disturbances
Risk Factors for sleep apnea
in children include:
z Obesity
z African-American race
z Sinus problems
z Persistent wheezing
Guideline for Diagnosis of
OSAS
1. All children should be screened for
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
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
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Children with OSA have marked increases in
healthcare-related costs
If prompt diagnosis and management are not
implemented some of these complications may
not be completely reversible, resulting in longlasting consequences
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
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Caregivers detected a long-term improvement in
quality of life following adenotonsillectomy for
OSA although the results were not uniform
Decreasing nasal congestion associated with
allergic rhinitis can improve sleep in these
patients and lead to improved daytime quality of
life
CPAP can be effectively used in children less
than 2 years of age
Treatment
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Children with primary snoring were unlikely to
develop polysomnography-confirmed OSA and
therefore delayed treatment was safe
For patients with residual problems following
adenotonsillectomy, collaboration with
orthodontists to improve craniofacial risk factors
should be considered
Summary
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Failure to diagnose and treat these patients can
result in serious but usually reversible problems
which may include impaired growth,
neurocognitive and behavioral dysfunction and
cardiorespiratory failure
Identifying these patients may be difficult
because they may not exhibit signs or symptoms
while awake
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