Obstructive sleep disorder

GREETINGS FROM YENEPOYA DENTAL COLLEGE
Indian Dental Conference 2008, Mangalore
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

OBSTRUCTIVE SLEEP
APNEA –
A Dentist’s Perspective
Dr Varghese K Paulose
Department of Orthodontics
Yenepoya Dental College
Mangalore
Under the Guidance:
Dr Rohan Mascarenhas, Professor Dr Akhter Husain, Professor & H.O.D

INTRODUCTION
 Greek word apnea, which means "without breath."
 serious sleep disorder
 stop breathing for 10 to 30 seconds at a time
 short stops in breathing can happen up to 400 times every
night

 Obstructive Apnea-a cessation of airflow-at least 10 s w/
continued effort to breathe
 Central Apnea-apnea w/ no effort to breathe
 Mixed Apnea-apnea begins as central but towards end there is
effort to breathe without airflow
INTRODUCTION

RISK FACTORS

 Excessive weight gain
 accumulation of fat on the sides of the upper airway causes
it to become narrow and predisposed to closure when the
muscles relax
 Age
 Loss of muscle mass is a common consequence of the
aging process
 Men have a greater risk for OSA
 Male hormones can cause structural changes in the upper
airway
RISK FACTORS

RISK FACTORS
 Anatomic abnormalities, such as a mandibular retrognathia
 Enlarged tonsils and adenoids, the main causes of OSA in
children
 Family history of OSA, although no genetic inheritance pattern
has been proven
 Use of alcohol and sedative drugs, which relax the musculature
in the surrounding upper airway

 Smoking, which can cause inflammation, swelling, and
narrowing of the upper airway
 Enlarged tongue - Hypothyroidism, Acromegaly, Amyloidosis,
Vocal cord paralysis, Post-polio syndrome, Neuromuscular
disorders, Marfan's syndrome, and Down syndrome
 Nasal congestion
RISK FACTORS
While obesity is clearly a risk factor for sleep apnea, sleep apnea is
multi-factorial and occurs among people in all weight category.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
 tissue laxity and redundant mucosa
 anatomic abnormalities
 decreased muscle tone with REM sleep
 airway collapse

PATHOPHYSIOLOGY
 Desaturation
 Arousal with restoration of airway
 Sleep fragmentation leading to hypersomnolence

SYMPTOMS
 Loud snoring
 Excessive daytime sleepiness
 Falling asleep easily and sometimes inappropriately
 High blood pressure
 Other cardiovascular complications
 Morning headaches
 Memory problems
 Feelings of depression
 Reflux
 Nocturia
 Impotence

OSAHS – Diagnosis
 The following questions should be asked whenever a diagnosis
of OSAHS is being considered
 Is the patient falling asleep regularly against their will?
 Is this patient often sleepy whilst driving?
 Is this patient experiencing difficulties at work because of
excessive sleepiness?
 Is surgery for snoring being contemplated?

THE EPWORTH SLEEPINESS
SCALE
 How likely are you to doze off or fall asleep in the following
situations in contrast to just feeling tired? This refers to your
usual way of life in recent times. Even if you have not done
some of these things, try to work out how they would have
affected you.
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

 Situation Chance of Dozing
 Sitting and reading
 Watching TV
 Sitting inactive in a public place (e.g.. a theatre or a meeting)
 As a passenger in a car for an hour without a break
 Lying down to rest in the afternoon when circumstances
permit
 Sitting and talking to someone
 Sitting quietly after a lunch without alcohol
 In a car, while stopped for a few minutes in traffic
 TOTAL (max. 24)

OSAHS – Diagnosis
 Epworth Sleepiness Scale – a validated method of assessing
the likelihood of falling asleep in a variety of situations
 Normal – ESS <11
 Mild daytime sleepiness – ESS 11 – 14
 Moderate daytime sleepiness – ESS 15-18
 Severe daytime sleepiness – ESS >18
 Correlation between ESS and OSAHS is relatively weak, but
gives a guide to the patients perception of his/her sleepiness

OSAHS – Diagnostic Tools
 Full Polysomnography
 Costly and complex
 Investigation of choice for a minority of patients
 Limited sleep studies
 Cost effective, convenient for patients, speeds up the
investigation pathway
 Overnight sleep studies
 A good screening tool

 Electro-encephalography (EEG) - brain wave monitoring
 Electromyography (EMG) - muscle tone monitoring
 Recording thoracic-abdominal movements - chest and
abdomen movements
 Recording oro-nasal airflow - mouth and nose airflow
 Pulse oximetry - heart rate and blood oxygen level monitoring
 Electrocardiography (ECG) - heart monitoring
 Sound and video recording
Overnight Polysomnography

Overnight Polysomnography

Polysomnographic Criteria For OSA
Criteria Adults Children
(one to 12
years of age)
Apnea-Hypopnea Index* >5 >1
Minimum Oxygen Saturation (%) <85 <92
The apnea- hypopnea index is the average number of apneas
and hypopneas per hour of sleep

OSAHS - Severity
 Measured using the apnoea/hypopnoea index (AHI) or the
respiratory disturbance index (RDI)
 Mild – AHI 5 – 14 / hour
 Moderate – AHI 15 – 30 / hour
 Severe – AHI > 30 / hour

OSAHS – Treatment
 Behavioural interventions
 Non-surgical interventions
 Surgical interventions

OSAHS – Treatment
Behavioural interventions
 May be sufficient in simple snorers or in those with very mild
OSAHS and few symptoms
 Weight loss in obese patients
 Alcohol and sedatives should be avoided
 Non-sleepy snorers should be discouraged from sleeping on
their backs

OSAHS – Treatment
CPAP
 Pneumatic splint to maintain upper airway patency
throughout all phases of sleep
 Treatment of choice
 Improves subjective and objective sleepiness, cognitive
function, vigilance, mood and quality of life measures.
 Best results are obtained in those with an AHI of >15
 Side effects: epistaxis, sinusitis, rhinitis, dryness of the
nasal passages, nasal bridge sores, claustrophobia,
abdominal bloating, mouth leaks and noise

Continuous Positive Airway Pressure
(CPAP)

OSAHS – Treatment
Surgical interventions
 Uvulopalatopharyngoplasty (UPPP) – poor and unpredictable
 Tonsillectomy
 Tracheostomy
 Mandibular advancement
 Bariatric surgery
 Nasal surgery

Uvulopalatopharyngoplasty

Maxillo-mandibular
advancement

 adjustable and nonadjustable
 Anterior tongue repositioners
 Mandibular posturing devices
 Soft palate or uvula lifting devices
OSAHS – Oral Appliances

Anterior Tongue Repositioners
 advances the tongue
 tongue & mandible together with adjacent soft tissue
 increases the posterior airway space
 increases the activity of the genioglossal & lateral pterygoid
muscles
 effects a stretch induction of the pharyngeal motor system

Tongue- Retaining Devices (TRD)

Mandibular Posturing Devices
 Also alters position of the hyoid and modify the
hypopharyngeal airway space

Nocturnal Airway-Patency Appliance
(NAPA)

Herbst Appliance
Standard plunger-tube Telescopic connector

Klearway Appliance

Silicone Positioner Appliance

Other Appliances

Soft Palate or Uvula Lifting Devices
 reduce soft tissue vibrations that result in snoring

Best????
 Although there are logical clinical reasons for using different
appliances, there is not enough scientific evidence for the
clinician to determine which appliance is most likely to improve
symptoms for a given patient

Consequences of untreated OSAHS
 Six fold increase in RTA (20% due to sleepiness at the wheel)
 Impairment of cognitive function
 Impairment of mood
 Personality changes
 Reduction in quality of life
 Impaired relationships
 Increased risk of hypertension, IHD and strokes

Conclusion
 Dental professionals can, and should, play an active role in
 screening patients for the disease
&
 providing oral appliance therapy (OAT) when a sleep
specialist physician has prescribed it

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Obstructive sleep disorder

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