The document summarizes guidelines from the American Association of Orthodontists on the role of orthodontists in screening for and managing obstructive sleep apnea. It discusses how orthodontists can screen patients for risk factors and signs of sleep apnea. It also outlines how orthodontic treatments like oral appliances and orthognathic surgery can be used to treat sleep apnea in collaboration with physicians. The document separates discussions on adult and pediatric sleep apnea, covering etiology, risk factors, symptoms, diagnosis, and treatment approaches for each.

1. DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL
ORTHOPAEDICS.
JOURNAL CLUB PRESENTATION.
Obstructive sleep apnea and Orthodontics: An American
Asoociation of Orthodontists White Paper.
Rolf g. Behrents, Anita V. Shelgikar, R.Scott Conley, Carlos Flores Mir, Mark Hens,
Mitchell Levine, J.A. McNamara,J.M.Palamo ,B.Pliska, J.W. Stockstill, John Wise,
S. Murphy, NormanJ. Nagel and J. Hittner.
Presented by: Guided by:
Dr. Deeksha Bhanotia Dr. Mridula Trehan.
M.D.S. First year. Professor & Head.
NIMS Dental College and Hospital Department of Orthodontics
and Dentofacial Orthopaedics

2. Introduction:
The speciality of Orthodontics involves much
more than just moving the teeth, and the management of
sleep apnea bears witness to this. As such there is
increasing interest in the role of the orthodontist both in
screening for obstructive sleep apnea and as a practitioner
who may be valuable in the multidisciplinary
management of Obstructive Sleep Apnea both in children
and adults.

3. As experts in the science of facial growth and
development, combined with the knowledge of Oral
devices, Orthodontist are well suited to collaborate
with physicians and other allied health providers in
the treatment of Obstructive Sleep Apnea.

4. Ways suspected Obstructive Sleep Apnea
Patient come to an Orthodontist:
1. A diagnosed Obstructive Sleep Apnea patient may
be referred to the orthodontist by physician who
prescribes an oral appliance or suggests orthodontic
or orthopedic therapy to assist in the management of
Obstructive sleep Apnea.
2. Patient or caregivers may present to the orthodontist
with concerns about breathing during sleep.

5. 3. Patient may present unaware of their Obstructive
Sleep Apnea and orthodontic screening may reveal the
need for further evaluation by a physician.

6. Adult Obstructive Sleep Apnea:
Sleep- related breathing disorders (SRBDs) constitute
a diagnostic category of disease that encompasses
obstructive phenomena, including:
1. primary snoring.
2. upper airway resistance syndrome.
3. Obstructive Sleep Apnea
along with related entities of central sleep apnea and
sleep related hypoventilation.

7. Etiology:
Obstructive sleep apnea occurs as a function of
increased collapsibility of the upper airway.
The pharyngeal Critical Closing Pressure
(Pcrit) is the pressure at which the upper airway
collapses.
This collapsibility is influenced further by
impaired muscular tone.

8. Respiratory effort increases to maintain the airflow through a
constricted airway, accompanied by relative increase in
serum carbon dioxide (hypercarbia) and decrease in serum
oxygen (hypoxemia).

9. The increased work of breathing causes a cortical
arousal from sleep, which in turn raises sympathetic neural
activity leading to increased heart rate and blood pressure and
a tendency for cardiac arrhythmia.
Complexity of Obstructive Sleep Apnea is exemplified by
its multifactorial etiology.
It involves the craniofacial structures, neuromuscular tone,
etc.

10. Prevelance:
Obstructive Sleep Apnea is commonly thought to
involve 14% of men and 5% of women. Prevelance rate is
higher in obese patients considered for bariatric surgery and
post stroke patients.

11. Risk Factors:
Conditions that may be risk factors for development
of Obstructive sleep Apnea are:
1. Obesity [ BMI]>=30 kg/sq.m
2. Menopause.
3. Increasing age.
4. Genetic influence on craniofacial structure.
5. Retrognathia.
6. Long narrow faces.
7. Narrow and deep palate.
8. Anterior open bite.
9. Mid face deficiency.
10. Lower hyoid position .

12. Symptoms
Common symptoms of Obstructive Sleep Apnae
are:
1. History of Snoring, gasping respiration or choking and
witnessed pauses in breathing (apneas) during sleep.
2. Nocturnal awakenings, Non restorative sleep, morning
headaches and excessive day time sleepiness.
3. Patient have difficulty with attention and concentration,
mood disturbances.
4. Difficulty in controlling other medical condition such
as diabetes mellitus, hypertension and obesity.

13. Diagnosis:
Gold standard for diagnosis is by an in center overnight
sleep study called as Polysomnography[ PSG] .
Home Sleep Apnae Test [HSAT] is a type of out-of-
center sleep testing.

14. Poly somonography test includes at least 7 channels
of recording including
Electroencephalography, Electrocardiography,
monitoring of sleep, airflow through nose and
mouth, pulp oximetry, Respiratory effort and leg
movement.

15. According to international Classification of sleep
disorders OSA can be diagnosed by either of 2 sets of
criteria:
First Criteria
1. The patient has sleepiness, non
restorative sleep, fatigue or
insomnia symptoms.
2. The patient wakes with breath
holding, gasping or choking
3. A bed partner or other observer
reports habitual snoring, breathing
interruptions or both during
patient’s sleep.
4. The patient has been diagnosed with
hypertension, a mood disorder,
cognitive dysfunction etc.
Polysomonography shows at
least 5 predominantly obstructive
events per hour of sleep.
Second Criteria
1. Obstructive sleep apnea can be
diagnosed if Polysomnography or out
of center Testing (OCST) shows 15 or
more obstructive events (Obstructive
or mixed apneas, hypopneas or
Respiratory Effort Related Arousals
per hour of sleep during a PSG or per
hour monitoring on OCST.)

16. Severity:
Mild: (AHI or RDI >=5 and <15)
Moderate: (AHI or RDI >=15 and <30)
Severe: (AHI or RDI >=30)
Respiratory Disturbance Index: (RDI): Number of apneas,
hypopneas and Respiratory effort Related Arousals(RERAs) per
hours of sleep.
Apnea Hypopnea Index(AHI): Number of apneas and hypopneas
per hour of sleep.

17. Role of Orthodontics in Adult
Obstructive Sleep Apnae
The orthodontist is well positioned to perform
an Obstructive Sleep Apnea screening assessment
and refer at risk patients for diagnostic evaluation.
Once the diagnosis is confirmed physicians may
prescribe orthodontic appliances or procedures in
appropriately selected adult patients as part of
Obstructive Sleep Apnea Management.

18. Medical and Dental History
Following is considered when constructing a health history
that is sensitive to Obstructive Sleep Apnea:
a. A previous diagnosis of OSA.
b. Excesive day time sleepiness.
c. Fatique during day
d. Chocking or gasping respiration during
sleep.
e. Observed episodes of pauses in
breathing.
f. High blood pressure.
g. Awakening dry mouth or sore throat

19. h. mouth breathing.
i. morning headaches.
j. menopause.
k. disordered mood.
l. attention or memory problem
m. nasal obstruction
n. bruxism.
o. type 2 diabetes.

20. Screening Tools:
In adults, a validated tool for Obstructive Sleep Apnea
risk assessment is the STOP-Bang questionnaire which
asks yes or no questions based on its acronym:
snoring(S),
tiredness(T),
Observed pauses in breathing (O),
high blood pressure (P),
BMI >35 kg/m2 (B),
age >50 years(A),
neck circumference of >=17 inches
in male or >= 16 inches in female.(N)
Male Gender(G)

21. A patient is considered to be :
a. Low risk for OSA if has no more than 2
“yes” answers.
b. Intermediate Risk if there are 3 or 4
“yes” answers.
c. High risk if there are 5 or more “yes”
answers.
d. Patient is considered at high risk also if
there are 2 “yes” answers from STOP section
combined with male gender, high BMI, or large neck
size.

22. Using a cutoff score of >= to detect any OSA (AHI >5),
moderate to severe OSA (AHI >15), and severe OSA
(AHI>30), the sensitivities were 84%, 93% and 100%.
The sensitivity gives the practitioner an excellent tool
for identifying patients who have the condition.

23. Clinical Examination:
The clinical Examination is an important part of
the screening process.
Orthodontist can use Modified Malampati
(MM) classification to describe the patency of the
oral airway. Three steps are followed to determine
the MM class:
Step 1: Patients are asked to take a seated or supine Position
Step 2: Patients are asked to protude their tongue as far as
forward as they can without emitting a sound.
Step 3 :The examiner observes the relationship between the
palate, tongue base and other soft tissue structure.

24. Malampati Classification:
Class I: Soft palate, fauces (the arched opening at
the back of the mouth leadng to pharynx), uvula
and tonsillar pillars are visible.
Class II: Soft palate, fauces, and uvula are visible.
Class III: Soft palate and base of uvula are visible.
Class IV: Soft palate is not visible.

25. Orthodontic Radiographs:
Conventional Cephalometric images are dimensionally
limited. Therefore airway imaging with the use of a Lateral
Cephalogram does not portray mediolateral information in
the oropharyngeal airway and may give misleading
information as to the volume and minimal cross sectional
area.

26. Cone Beam Computed Tomography (CBCT) images
have been shown to be useful in diagnostic and
morphometric analysis of the hard and soft tissues in routine
orthodontic treatment, but they have certain limitations
regarding the diagnosis of OSA. CBCT provides no
information on neuromuscular tone, susceptibility to
collpase, or actual function of the airway.

27. Diagnosis and Treatment Planning in
adult OSA
If the patient is found to have Obstructive
Sleep Apnea , the physician will prescribe the
appropriate course of action; the orthodontist should
consider working in a collaborative way with the
physician, providing related orthodontic treatment
when necessary and when it does not interfere with
medical treatment.

28. Treatment of OSA in Adults by Physicians
and Surgeon:
Positive Airway Pressure (PAP) therapy is the Gold
standard treatment for Obstructive Sleep Apnea in adults.
Positive airway Pressure is delivered through a mask
interface as either continuous positive airway pressure
(CPAP), bi-level positive airway pressure(BPAP) , or
autotitrating positive airway pressure (APAP).

29. Other treatment options include positional
therapy (avoidance of sleeping on back) and long term
weight reduction as indicated. Nasal congestion and allergic
rhinitis may be managed with the use of nasal steroids and
other oral medications as indicated.
For selected patients multilevel surgery includes nasal
and palatal surgery with or without mandibular surgery,
genioglossus advancement and hyoid suspension are
considered.

30. Other soft tissue surgeries might be indicated
that involve the tonsils, adenoids , frenum and
tongue.
Hypoglossal Nerve stimulation addresses the
impaired neuromuscular tone in OSA and may be
considered in certain patients with OSA.

31. Orthodontic Management In Adult OSA
After diagnosis of OSA by a physician , a
patient may be referred to an Orthodontist for one
or more types of care.
Informed Consent:
Before initiating care , informed
consent appropriate to OSA must be obtained before
a treatment is provided. The proposed treatment
plan should be described in detail and treatment
alternatives should also be discussed.

32. Oral Appliance Therapy:
Oral appliances, which includes both mandibular
advancing oral appliances and tongue retaining
devices are usually effective options for OSA
management in appropriately selected patients.
Advancing oral appliances are intended to hold
the mandible or associated soft tissues forward
resulting in increased caliber of upper airway at
the oropharyngeal level.

33. Functional Appliances and Mandibular advancing oral
appliances are considered to be the first line of treatment
for patients that prefer Oral appliances over Positive airway
pressure and for those patients that do not respond to
positive airway pressure therapy.

34. Many types of Oral Appliances are used in the treatment
of Obstructive sleep Apnea in patients.
The appliances are based on the coupling design, mode of
fabrication and activation, titration capability, degree of
vertical opening, lateral jaw movement and whether they
are custom made or pre fabricated.

35. Oral Appliance Titration
Oral appliances initially are delivered with the mandible
advanced to a position approximating two –thirds of
maximum protrusion. After a period of accommodation,
based on subjective feedback from the patient regarding their
Obstructive Sleep Apnea symptoms and sleep quality the
amount of protrusion can be titrated or increased until
optimum symptom relief is obtained.
The physician involved should be requested a sleep study
with Oral appliance in place.

36. Monitoring
During treatment for OSA , the patient should be
monitored which may involve subjective reports as well as
objective observations.
Reports on usage of the Oral Appliances may be obtained
from patient and bed partner or caregiver.
It has been suggested that monitoring be conducted at
least once every 6 months during the first year and then
annually.

37. Goals of Treatment:
1. Change in Occlusion:
Oral appliances used in sleep apnea
treatment move teeth. Typical treatment
changes includes changes in overjet and
overbite, changes in facial height, treatment of
anterior crossbites and posterior open bites.

38. 2.Maxillomandibular advancement and Surgically
assisted Rapid maxillary Expansion:
Patients who are unable to tolerate or adhere to
positive airway pressure or Oral appliances with an
underlying discrepancy may be a candidates for
maxillomandibular advancement or tengnathic (>10
mm) jaw advancement surgery.

39. Pediatric Obstructive Sleep Apnea:
Etiology same as that of the adult Obstructive Sleep
Apnea.
Obstructive sleep apnea occurs as a function of
increased collapsibility of the upper airway.
The pharyngeal Critical Closing Pressure (Pcrit) is
the pressure at which the upper airway collapses.
This collapsibility is influenced further by impaired
muscular tone.
Respiratory effort increases to maintain the airflow
through a constricted airway, accompanied by relative
increase in serum carbon dioxide (hypercarbia) and decrease
in serum oxygen (hypoxemia).

40. Risk Factors:
1.Obesity.
2. Craniofacial Morphology
a. Mandibular Retrognathia.
b. Long and Narrow faces.
c. Narrow and deep palate.
d. Steep mandibular plane angle
e. anterior open bite.
f. Mid face defeciency
3. Genetic syndromes :
a. Pierre Robin syndrome.
b. Down syndrome.
c. Syndromic craniosynostosis

41. Symptoms:
History of Snoring, gasping respiration or choking
and witnessed pauses in breathing (apneas) during
sleep.
Diagnosis:
Diagnosis of OSA in children is confirmed only by
the gold standard Polysomnography.
Severity:
Mild --- AHI or RDI >=1 and < 5/h
Moderate---- AHI >=5<10/h
Severe----AHI >=10/h

42. Prevelance:
Prevelance is found to be 1.5% -6%

43. Role of Orthodontics in Pediatric OSA
It is strongly recommended that the Orthodontist
perform a clinical assesment for OSA and refer at
risk patients to appropriate physician for definitive
diagnosis of OSA.

44. Medical and Dental History
Following is considered when constructing a
health history that is sensitive to Obstructive Sleep
Apnea:’
a. snoring.
b. sleep related behaviours.
c. day time sleepiness.
d. mouth breathing during sleep.
e. morning headaches.
f. fall asleep quickly.
g. nasal obstruction.
h. attention deficit hyperactivity disorder.

45. Screening Tools:
The screening tool that has been validated and used
in in Orthodontic offices is the Pediatric Sleep
Questionnaire

46. Diagnosis and Treatment Planning
The plan for treating pediatric OSA should be based on
consideration of patient’s individual needs and treatment
goals.
Two orthodontic procedures that may change upper
airway physiology are:
a. Rapid Maxillary Expansion for maxillary
transverse defeciency.
b. Mandibular Advancement appliances for Class
II corrections.

47. Treatment:
In the growing child , Obstructive Sleep Apnea
management is dramatically different than for the adult.
Hypertrophic tonsils and adenoids are the most common
risk factors for OSA in pediatric population with
tonsillectomy and adenoidectomy typically considered as
first line of treatment.
Various forms of pharmacologic agents may be
prescribed by the attending physician to reduce the size of
nasal soft tissues . Nasal surgery , including turbinate
reduction and deviated nasal septum correction may be
considered in selected cases.

48. Dentofacial orthopedic management, which is within the
scope of the orthodontic specialist, also may be considered.
Eg: RME is well known orthodontic treatment option for
patients with a narrow maxilla.
Orthognathic surgery is not indicated until
craniofacial growth is completed. An exception might be
considered in a case where the patient has OSA and a severe
skeletal discrepancy. After considering the potential benefits
and risks involved , orthodontic or telegnathic surgery could
be considered.

49. Fallacies about Orthodontics in Relation
to OSA
Conventional orthodontic treatment has never been
proven to be an etiologic factor in the development of OSA.
Misinformation exists regarding the potential airway related
sequelae of orthodontic treatment performed with the use of
dental extractions or orthopaedic head gear.
However existing evidence in the literature does not
support the notion that arch constriction or retraction of the
anterior teeth facilitated by dental extractions. Head Gear
also do not pose an increased risk to airway in that the
airway remains the same or increases over the study
periods.

50. Conclusion
Obstructive Sleep apnea is a medical disorder that
can have many serious consequences if left untreated . OSA
can affect adults and children and can present at any point
in the lifespan. When an orthodontist has a clinical suspicion
that a patient may have OSA , it is strongly recommended
that referral to a physician be made. Individual orthodontists
may elect to participate in the treatment and monitoring of
OSA patients as appropriate and permissible under
applicable laws, standards of care and insurance coverage.

51. RELATED ARTICLES:
Predictors of long-term orthodontic side effects from mandibular
advancement devices in patients with snoring and obstructive sleep apnea
Marie Marklund Umeå, Sweden
Introduction: Orthodontic side effects can complicate the long-term use of mandibular
advancement devices (MADs) in the treatment of patients with snoring and obstructive
sleep apnea. The aim of this study was to find predictors of dental side effects from
monoblock MADs.
Methods: Four hundred fifty patients, who consecutively received treatment with either
soft elastomeric or hard acrylic devices, were followed up after 5.4 0.8 years (mean SD).
The continuing patients responded to questionnaires and had dental examinations and
plaster casts made.
Results: Twenty-seven patients had moved or died during the follow-up period. Two
hundred thirty-six of the remaining 423 patients (56%) continued treatment, and 187 of
them reported compliance rates of 50% at night. A small reduction in overjet of 1 mm was
associated with a deepbite with an overbite of 3 mm and an overjet of 3 mm (odds ratio
7.5; P = .015), nasal congestion ( 2.9; P=.005), or the use of a soft elastomeric device
(Odds ratio 2.7; P = .014) controlled for age, sex, treatment time, and mandibular
displacement. A small reduction in overbite of 1 mm was related to a small opening of the
mandible of 11 mm.
Conclusions: Orthodontic side effects might be predictable on the basis of initial
characteristics in dental occlusion and the design of MADs. (Am J Orthod Dentofacial
Orthop 2006;129:214-21)

52. Clinical Predictors of Obstructive Sleep Apnea
Michael Friedman, MD; Hasan Tanyeri, MD; Manuel La Rosa, DDS; Roy Landsberg,
MD; Krishna Vaidyanathan, MS; Sara Pieri, MD; David Caldarelli, MD
Objective: To identify physical findings that can be standardized to predict the presence
and the se- verity of obstructive sleep apnea (OSA).
Study Design: One hundred seventy-two patients who answered questionnaires with
responses that suggested they might have OSA were included in this prospective study.
Methods: All patients underwent a physical ex amination and polysomnography. The
physical exam- ination included the measurement of four parameters used by
anesthesiologistst o identify patients likely to have difficult intubation to determine if these
same parameters predict OSA. We recorded modified Mal- lampati grade (MMP), tonsil
size, and body mass in- dex (BMI) and measured thyroid-mental distance (TMD) and
hyoid-mental distance (HMD) in the study population.
Results: When the physical findings were correlated singly with the respiratory
disturbance in- dex (RDI), we found that MMP (P < .001), tonsil size grading (P = .008),
and BMI (P = .003) were reliable predictors of OSA. A greater correlation with OSA
emerged when an "OSA score" was formulated by fac- toring the MMP, tonsil grade, and
BMI grade (RDI = 7.816 x MMP + 3.988 x Tonsil Size + 4.675 x BMI - 7.544). A high
score was not only predictive of OSA but also correlated well with OSA severity. Neither
HMD nor TMD correlated with the severity of RDI.
Conclu- sions: An OSA score may help identify those patients who should have a full
sleep evaluation. Key Words: Obstructive sleep apnea, physical examination, prediction.