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Sleep apnea


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Sleep apnea

  1. 1. Snoring And Sleep ApneaSnoring and Obstructive Sleep Apnea: in the U.S.Oral Appliance Therapy Management Approximately 40% of adults over 40 years old snore (about 100 million Midwest Society of Orthodontists Americans) October 16-17, 2009 4% of men and 2% of women have signs and symptoms of OSA (about 12 million Americans) Anthony J DiAngelis DMD, MPH Chief, Department of Dentistry, HCMC Professor, University of Minnesota School of Dentistry OSA is as prevalent as diabetes or asthma Definitions Defining Severity of OSAApnea: Cessation of ventilation for > 10seconds Length of time in apnea eventHypopnea: 30-50% reduction in airflow > 10 Percentage decrease in oxygenseconds desaturationApnea Index (AI): Average number of Apnea-Hypopnea Index:apneic episodes per hour of sleep Mild OSA= 5-15 events/hour Moderate OSA= 15-30 events/hourApnea-Hypopnea Index (AHI): Average Severe OSA= >30 events/hournumber of apnea plus hypopneas per hour ofsleep. Obstructive Sleep Apnea Dangers of Obstructive Sleep Apnea Individuals with OSA: 5 x more heart attacks 30-45% high blood pressure 50% stroke patients have OSA Loss of Employment Uninsurability Marital Discord Increased Role of MVA’s (20%) 1
  2. 2. Clinical Signs & Symptoms Predisposing Factors Snoring: Intermittent with pauses Excessive daytime sleepiness Age: Prevalence progressively increases with advancing age Awakenings / gasping or choking Obesity: Prevalence progressively Fragmented, non refreshing Fragmented non-refreshing, light increases with increasing weight sleep Gender: 5 to 10 times more common in Poor memory, clouded intellect males Irritability, personality changes Disproportionate upper airway anatomy ET0H, sedative-hypnotic drugs in late PM Decreased sex drive, impotence Hypothyroidism Morning headaches Diagnosis Management of Snoring and OSA Non-Surgical Avoidance of risk factors Pharmacologic agents – not very effective Positive airway pressure (continuous or bilevel) Oral appliance therapy Surgical Tracheostomy Uvulopalatopharyngoplasty – UPPP LAUP Pillar Procedure Hyoid Suspension/Genioglossus Advancement Max. / Mand. Advancement How Do They Work? Oral appliances are worn in the mouth during sleep to preventOral Appliance Therapy the oropharyngeal tissues and p y g the base of tongue from collapsing and obstructing the upper airway. 2
  3. 3. Advancement = Increased Airway Oral Appliances May Function in 3 Basic Ways Repositioning the Mandible, Tongue, Soft Palate and Hyoid Bone Stabilizing the Mandible / Tongue / Hyoid Bone Increasing Baseline Genioglossus Muscle Activity Case Types Contraindications Primary Snoring Mild / Moderate OSA Central Sleep Apnea CPAP Intolerant – any level Significant TMJ Disorder ( g (MRD’S) ) Surgical Failures Inadequate Dental Status (MRD’S) Adjunctive Therapy Unmotivated Patient Occasional, Short-term Substitutive Therapy Functional Classification of Oral Appliances Categorized by Mode of Action: Mandibular Repositioners p Tongue Retainers 3
  4. 4. Design Variations Tongue Retaining Device (TRD)Method of RetentionFlexibility of MaterialAdjustability j yVertical OpeningFreedom of Jaw MovementLab vs. Office Construction PM Positioner TAP 3 TAP 3 Somnodent 4
  5. 5. KlearwayEvaluation and Consultation MD Referral Review Sleep Study Review History Oral E O l Examination i ti Informed Consent Models and George Gauge Bite MRD Type Letters to MD and Patient’s DDS 5
  6. 6. Side Effects and ComplicationsFinal GG bite registration Common Side Effects:Starting mandibulartreatment position is ▪ Excessive Salivation60% of maximum ▪ Transient Discomfort – Teeth, TMJprotrusion ▪ Dry MouthMinimum of 7mm ▪ S f Tissue Irritation Soft Ti I i iprotrusion needed3-5 mm interincisal ▪ Temporary, Minor Disharmoniesopening in anterior Complications:Mandible positioned ▪ Significant TMJ Discomfort/Dysfunctionsymmetrically ▪ Permanent Occlusal Changesforward MRD Success Rates Diagnosis % Success • snoring 90+ • mild OSA 80+ • moderate OSA 70+ • Severe OSA 50-50 Follow-up Evaluation During Periodic Follow Up Appliance TherapyMedical AssessmentDental Assessment History: ▪ Snoring ▪ Apneic Events ▪ Quality of Sleep ▪ Daytime fatigue (EDS) ▪ Focus ▪ Side Effects 6
  7. 7. Follow-up Evaluation During Follow-up Schedule During Appliance Therapy Appliance Therapy Examination: First Year: ▪ Appliance Fit and Comfort ▪ 3 weeks post insertion ▪ OB OJ OB, ▪ 3 month intervals ▪ Occlusal Contact Second Year: ▪ Muscle Tenderness ▪ 6 months ▪ TMJ Assessment Annual Thereafter Post MAD Recommend Follow-up Pre MAD 54 y.o. Female 56 y.o Female Evaluation with Physician and PSG with Oral ApplianceFor patients with moderate to severe OSA: Refer for s eep study when pat e t has e e o sleep e patient as relief of symptoms During study, mandibular position is advanced 1 mm/1/2 hour, if needed, until estimated AHI is below 10 events/hour Long-Term Sequellae of Oral Appliance Therapy in Obstructive Sleep Apnea Almeida F R et al. Am J Orthod Conclusions Dentofac Orthop 129:195-213, 2006 Skeletal Types and Outcomes Long-term oral appliance therapy affects the Class I Class II/l Class II/2 Class III entire occlusion in all three dimensions:No Change 12.5% 10% 20% 50%FavorableFa orable 25% 90% 80% --- Transversely: Arch widths increase; y ; overjets decrease.Unfavorable 62.5% --- --- 50% Antero-posteriorly: Mandibular Other Findings dentition moves forward; anterior overjetsOverjet: Decreased anterior to mesial of the first molars decreaseOverbite: Significantly decreased in the entire archArch Width: Mandibular arch increased more than the maxillary Vertically: Overbites decreaseCurve of Spee: Flattened significantly in the premolar area after long-term therapy. 7
  8. 8. Tooth movement is much morecommon in patients who have had Risks vs. Benefits orthodontic therapy Our responsibility lies inTooth movement is guaranteed in adequately treating a medical patients who have had adult condition with a d t l d i diti ith dental device orthodontics . while recognizing and managing (as best we can) occlusal changes Alan Lowe BDS, PhD and to a lesser degree TMJ symptamotology. 8