This document provides an overview of obstructive sleep apnea (OSA), including its causes, symptoms, diagnosis, and management options. It discusses that OSA is characterized by repetitive collapse of the upper airway during sleep, disrupting breathing. Risk factors include obesity, male gender, age, and craniofacial abnormalities. Diagnosis involves questionnaires, physical exams, and polysomnography. Treatment includes positive airway pressure and oral appliances, which work by advancing the mandible to open the airway. Oral appliances effectively treat mild to moderate OSA and reduce snoring but have side effects like teeth pain that require follow-up.

1. Obstructive Sleep Apnea
(OSA)
Presented by: Dr. Hiral Joshi
3rd year Resident
Department of Prosthodontics,
Crown, and Bridge

2. Contents :
• What is sleep??
• Types of sleep
• Classification of sleep breathing disorders
• What is Obstructive Sleep Apnea (OSA)?
• Risk factors associated with OSA
• Complications associated with sleep apnea
• Pathophysiology OSA
• Symptoms associated with obstructive apneas

3. • Classification of OSA based on the severity
• Physical examination of OSA
• Diagnosis of OSA
• Imaging modalities
• Management of obstructive sleep apnea
• Oral Appliance Therapy (OAT)
• Contraindication of OAT
• Common side of OAT

4. What is sleep ?
• Sleep is the natural periodic state of rest for the mind and body with
closed eyes characterized by the partial or complete loss of
consciousness leads to decreased response to external stimuli and
decreased body movements.
Essentials of physiology - K .Sembulingum , 6th edition

5. • Each sleep cycle has 4-6 cycles , each cycle lasts for about average
90 minutes approx.
Sleep medicine for dentists. A practical overview.
Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith – 2009 edition

6. Types of sleep
• Rapid eye movement /REM
• Non-rapid eye movement/ NREM
Essentials of physiology - K .Sembulingum , 6th edition

8. • AASM 2009

9. Classification of sleep breathing
disorder
• There are four classification systems for sleep disorders that are
most frequently used:
1. Diagnostic Classification of Sleep and Arousal Disorders (DCSAD)
2. International Classification of Sleep Disorders, Second Edition
(ICSD-2)
3. International Classification of Diseases (ICD)
4. Diagnostic and Statistical Manual of Mental Disorders (DSM)

10. • In general, the DCSAD and ICSD-2 classification systems provide in
depth descriptive definitions that are employed for communication
purposes in the clinical fields of medical sleep specialists and
dentists
• whereas the ICD versions and their numerical codes are more
frequently used for medical records, billing purposes, and research
focused on epidemiological studies.

11. • The American Academy of Sleep Medicine along with the Japanese
Society of Sleep Research, Latin American Sleep Society, and
European Sleep Research Society published the International
Classification of Sleep Disorders (ICSD): Diagnostic and Coding
Manual in 1990,which was later revised in 1997.
• The most recent edition, International Classification of Sleep
Disorders, Second Edition (ICSD-2), was published in 2005

12. Sleep medicine for dentists. A practical overview.
Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith – 2009 edition

13. What is obstructive sleep apnea?
• OSA is characterized by the repetitive complete or partial
collapse of the upper airway during sleep, causing a
cessation (obstructive apnea) or a significant reduction
(obstructive hypopnea) of airflow
Sleep medicine for dentists. A practical overview.
Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith – 2009 edition

14. • An apnea is defined as a cessation of breathing for 10 seconds or
more.
• Hypopnea is most commonly defined as a decrease in airflow of
more than 50% or a decrease in airflow of more than 30% that is
associated with oxyhemoglobin desaturation (of greater than 3% or
4%)

15. • The severity of sleep apnea is commonly defined as the number of
apneas or hypopneas per hour of sleep, graded with the apnea-
hypopnea index (AHI):
1. 5 to 15 is considered mild;
2. 15 to 30 is considered moderate;
3. More than 30 is considered severe.

16. Risks factors
• Obesity
• Gender male>female
• Age
• Craniofacial and upper airway abnormalities
• Nasal obstruction
• Smoking
• Family history

17. • Exacberative factors : alcohol, BZDs, narcotics,
gabapentins, pre existing medical condition such as CKD
or end stage renal disease, arterial fibrillation,
pulmonary hypertension, stroke, pregnancy, Parkinson's
disease etc.

18. Jyothi, I. , Prasad,et. Al . Obstructive Sleep Apnea: A Pathophysiology and
Pharmacotherapy Approach. In: Vats, M. , editor. Noninvasive Ventilation in Medicine -
Recent Updates . London: IntechOpen; 2019

19. Arredondo E, Udeani G, Panahi L, et al. (September 09, 2021) Obstructive Sleep Apnea
in Adults: What Primary Care Physicians Need to Know. Cureus 13(9): e17843.

20. Stansbury RC, Strollo PJ. Clinical manifestations of sleep apnea. J Thorac Dis.
2015;7(9):E298-E310. doi:10.3978/j.issn.2072-1439.2015.09.13

21. Pathophysiology

25. Ali Madeeh Hashmi, MD Imran S. Khawaja, MD Awakening to the dangers of obstructive sleep apnea .
Current Psychiatry. 2014 February;13(2):58-61, 64-65

27. Based on severity
Seetho, Ian & O’Brien, Sarah & Hardy, Kevin & Wilding, John. (2014). Obstructive
sleep apnoea in diabetes - assessment and awareness. British Journal of Diabetes &
Vascular Disease. 14. 105.

28. Physical examination
• Obese
• Large neck (neck circumference >42cm in men, >37cm
in women)
• Retrognathia, micrognathia
• Crowded airway
• Enlarged tonsil
• Nasal deformities
• High arched palate

29. Gil, Hélène & Fougeront, Nicolas. (2015). Tongue dysfunction screening: assessment
protocol for prescribers. Journal of Dentofacial Anomalies and Orthodontics.

30. Sleep medicine for dentists. A practical overview.
Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith – 2009 edition

32. Clinical
guidelines for
OSA diagnosis
(AASM 2009)
• Collected data using sleep
oriented questionnaire
• Sleep oriented history and
physical examination
• Evaluation of the clinical
parameters
• In lab polysomnograghy/ home
testing with portable monitor
• Adjunctive imaging modalities :
MRI, Lateral Ceph

33. Questionnaire used:
NoSAS
score
Epworth
sleepiness
scale
STOP BANG
questionnaire
Berlin
questionnaire
Sleep
apnea
clinical
score

35. Sleep medicine for dentists. A practical overview.
Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith – 2009 edition
• The most frequently used instrument is
the Epworth Sleepiness Scale (ESS),
which was developed in 1991. The ESS
has been demonstrated to identify
degrees of sleepiness
• In using a scale of 0–3, where 0 indicates
no chance of dozing, 1 indicates a slight
chance, 2 indicates a moderate chance,
and 3 indicates a high chance, a total
maximum score of 24 is possible.
• Investigations have shown that a score of
10 or 11 is considered to be the upper
parameter for normal. While higher
scores correlate with sleep disorders.

36. Nagappa M. et al. Validation of the STOP-Bang Questionnaire as a Screening Tool for
Obstructive Sleep Apnea among Different Populations: A Systematic Review and Meta-
Analysis. PLoS One. 2015 Dec 14;10(12):e0143697.
• This meta-analysis
confirms the high
performance of the STOP-
Bang questionnaire in the
sleep clinic and surgical
population for screening of
OSA. The higher the STOP-
Bang score, the greater is
the probability of
moderate-to-severe OSA.

37. Imaging modalitis used:
• MRI
• Fluoroscopy
• Lateral cephalogram
• Nasopharngoscopy
(endoscopy)
• CBCT
Whytec Andy, Gibson Daren.IMAGING OF ADULT OBSTRUCTIVE SLEEP
APNOEA.European Journal of Radiology https://doi.org/10.1016/j.ejrad.2018.03.010

39. Guidelines by AASM & AADSM, 2015
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of
obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med 2015;11(7):773–827

40. 1. We recommend that sleep physicians prescribe oral appliances, rather
than no therapy, for adult patients who request treatment of primary
snoring (without obstructive sleep apnea). (STANDARD)
2. When oral appliance therapy is prescribed by a sleep physician for an
adult patient with obstructive sleep apnea, we suggest that a qualified
dentist use a custom, titratable appliance over non-custom oral devices.
(GUIDELINE)
3. We recommend that sleep physicians consider prescription of oral
appliances, rather than no treatment, for adult patients with obstructive
sleep apnea who are intolerant of CPAP therapy or prefer alternate
therapy. (STANDARD)
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the
treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep
Med 2015;11(7):773–827

41. 4. We suggest that qualified dentists provide oversight— rather than no
follow-up—of oral appliance therapy in adult patients with obstructive
sleep apnea, to survey for dental related side effects or occlusal changes
and reduce their incidence. (GUIDELINE)
5. We suggest that sleep physicians conduct follow-up sleep testing to
improve or confirm treatment efficacy, rather than conduct follow-up
without sleep testing, for patients fitted with oral appliances.
(GUIDELINE)
6. We suggest that sleep physicians and qualified dentists instruct adult
patients treated with oral appliances for obstructive sleep apnea to return
for periodic office visits— as opposed to no follow-up—with a qualified
dentist and a sleep physician. (GUIDELINE)
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the
treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep
Med 2015;11(7):773–827

42. • For patients with obstructive sleep apnea (OSA), snoring, or upper airway
resistance syndrome (UARS), the primary type of therapy is positive airway
pressure (PAP). However, a significant challenge to both patients and
health care practitioners is compliance (acceptance/adherence) to PAP
therapy
Dental Management of Sleep Disorders. Ronald Attanasio, DDS, MSEd, MS Dennis R.
Bailey, DD. 2010 edition

43. • There are three primary types of PAP modes:
A. Continuous positive airway pressure (CPAP),
B. Bilevel positive airway pressure (BiPAP)
C. Auto-adjusting positive airway pressure (APAP). A fourth mode
receiving some attention is the expiratory pressure relief mode
(Flexible CPAP).
Dental Management of Sleep Disorders. Ronald Attanasio, DDS, MSEd, MS Dennis R.
Bailey, DD. 2010 edition

44. Oral appliance therapy:
• Oral appliances can be divided into three main categories, based on
their mode of action
I. Soft palate lifters
II. Tongue Retaining Device (TRDs)
III. Mandibular Advancement Devices (MADs)
Dieltjens, Vanderveken. Oral Appliances in Obstructive Sleep Apnea. Healthcare
2019;7:141.

45. • The evidence available at present indicates that
oral appliances successfully “cure” mild-to
moderate sleep apnea in 40–50% of Patients,
and significantly improve it in additional 10–
20%. They reduce, but do not eliminate snoring.
Side effects are common, but are relatively
minor.
Divya Chandra S et al. Obstructive Sleep Apnea and its Prosthodontic Management
International Journal of Health Sciences & Research Vol.8; Issue: 3; 262March 2018

46. 1. Soft palate lifting – the prosthesis lifts and/or stabilizes
the soft palate, preventing vibration during sleep

47. 2. Tongue retention – tongue-retaining devices (TRDs) incorporate an
anterior hollow bulb, which generates a negative pressure vacuum
when the tongue is inserted. The tongue is held forward, away from
the posterior pharyngeal wall, opening up the airway. Owing to
muscle anatomy, this appliance simultaneously modifies the
position of the mandible.

48. • The MAD is the most common type of oral appliance therapy used
for the treatment of OSA.
• The mechanism of action of the MAD is usually assumed to cause the
enlargement of the cross-sectional upper airway dimensions by
anterior displacement of the mandible and the attached tongue,
resulting in improved upper airway patency.
• The devices one piece (monobloc) or two pieces (bibloc), and are
either custom-made or prefabricated
Rashed, R & Heravi, Farzin. (2006). Obstructive Sleep Apnea. journal of Dentistry(
Tehran). 3. 45-56.

49. • Furthermore, they may be adjustable (titratable) or nonadjustable.
Such as:
Rashed, R & Heravi, Farzin. (2006). Obstructive Sleep Apnea. journal of Dentistry(
Tehran). 3. 45-56.
Herbst appliance
Twin Block appliance

50. Karwetzky activator
Klearway appliance
TAP
Somnofit Somnoguard
Rashed, R & Heravi, Farzin. (2006). Obstructive Sleep Apnea. journal of Dentistry(
Tehran). 3. 45-56.

52. • The patient 63 year old female patient had an apnea-hypopnea index (AHI) of
13.3 event/h and a minimum oxyhemoglobin saturation of 75%
• The acrylic resin bases were prepared with heat-polymerized acrylic resin and
the patient’s vertical dimension of occlusion increased by 3 mm.
• A monoblock sleep device was prepared and delivered to the patient. Half palatal
coverage was used, and retention of device was provided with undercuts of teeth.

54. Results :
•AHI decreased 13.3 to 3.0
•Shorting of apnea duration from 31.5 sec
to 16.5 sec
•O2 desaturation index reduced from 16.4
to 3.4
•The occurrence of the snoring the sleep
was also decreased

55. Contraindication of oral appliance
• Inadequate number of sound teeth <8
• Severe periodontal disease
• Severe TMD
• Inadequate protrusive range <5mm
• Severe gag reflex
• Lack of coordination or dexterity
• Adolescents/pediatrics??
Ann Sales et al .Obstructive Sleep Apnea And It’s Management: A Prosthodontic
Perspective. 2015

56. Common side effect
• Masticatory muscle pain (transient)
• Dental pain/soreness
• Hyper-salivation
• Dry mouth
• TMJ pain/ tenderness
• Occlusal changes
• Tooth mobility
Doff et al. Clin oral invest (2012)(2013)
Freguson, KA et al. Sleep (2006)

57. Conclusion
• Sleep and dreams are taken for granted by those not affected by obstructive
sleep apnea. Unfortunately in around 10 million population around the
world, sleep is a nightly battle which leaves it‟s victims and their bed
partners fatigued, stressed and much less healthy.
• Untreated sleep apnea is one of the major public health issues we face in
common. The emergence of dental sleep medicine as a safe and effective
treatment brings hope for the millions of patients looking for alternatives to
CPAP treatment.
• Oral appliances used to date constitute a relatively heterogeneous group of
devices for the treatment of sleep apnea and non-apneic snoring.
• As dental professionals, we have a significant role to play in the early
diagnosis, management and care of patients suffering from sleep apnea.
Oral appliances play a major role in the non surgical management of OSA
and have become the first line of treatment in almost all patients suffering
from OSA.

58. • The interplay between anatomic, functional, and neural factors that
influence the upper airway patency during wakefulness and sleep is
still unclear. Although the role played by the prosthodontists is still
in its infancy, there is much to learn and understand in the rapidly
evolving field of sleep medicine.
• The growing interest of prosthodontists in sleep medicine has
contributed immensely toward effective prevention and treatment of
OSA and sleep Bruxism for each patient based on his/her individual
requirement

59. References
• Essentials of physiology - K .Sembulingum , 6th
edition
• Textbook of medical physiology – Guyton and Hall – 2nd edition
• Sleep medicine for dentists. A practical overview. Gilles J. Lavigne,
Peter A. Cistulli, Michael T. Smith – 2009 edition
• Ali Madeeh Hashmi, MD Imran S. Khawaja, MD Awakening to the
dangers of obstructive sleep apnea . Current Psychiatry. 2014
February;13(2):58-61, 64-65
• Jyothi, I. , Prasad,et. Al . Obstructive Sleep Apnea: A
Pathophysiology and Pharmacotherapy Approach. In: Vats, M. ,
editor. Noninvasive Ventilation in Medicine - Recent Updates .
London: IntechOpen; 2019

60. • Gil, Hélène & Fougeront, Nicolas. (2015). Tongue dysfunction
screening: assessment protocol for prescribers. Journal of
Dentofacial Anomalies and Orthodontics.
• Nagappa M. et al. Validation of the STOP-Bang Questionnaire as a
Screening Tool for Obstructive Sleep Apnea among Different
Populations: A Systematic Review and Meta-Analysis. PLoS One.
2015 Dec 14;10(12):e0143697.
• Whytec Andy, Gibson Daren.IMAGING OF ADULT OBSTRUCTIVE
SLEEP APNOEA.European Journal of Radiology
https://doi.org/10.1016/j.ejrad.2018.03.010
• Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM,
Chervin RD. Clinical practice guideline for the treatment of
obstructive sleep apnea and snoring with oral appliance therapy: an
update for 2015. J Clin Sleep Med 2015;11(7):773–827

61. • Dental Management of Sleep Disorders. Ronald Attanasio, DDS, MSEd,
MS Dennis R. Bailey, DD. 2010 edition
• Dieltjens, Vanderveken. Oral Appliances in Obstructive Sleep Apnea.
Healthcare 2019;7:141.
• Rashed, R & Heravi, Farzin. (2006). Obstructive Sleep Apnea. journal of
Dentistry( Tehran). 3. 45-56.
• Doff et al. Clin oral invest (2012)(2013)
• Freguson, KA et al. Sleep (2006)
• Arredondo E, Udeani G, Panahi L, et al. (September 09, 2021) Obstructive
Sleep Apnea in Adults: What Primary Care Physicians Need to Know.
Cureus 13(9): e17843.
• Stansbury RC, Strollo PJ. Clinical manifestations of sleep apnea. J Thorac
Dis. 2015;7(9):E298-E310. doi:10.3978/j.issn.2072-1439.2015.09.13

62. • Divya Chandra S et al. Obstructive Sleep Apnea and its
Prosthodontic Management International Journal of Health
Sciences & Research Vol.8; Issue: 3; 262March 2018