1. Sleep Apnea Prepared by: dr. Mohamad Ghazi 1 2. Outline: • Sleep Apnea definition • Epidemiology • Types of Sleep Apnea • Risk factors for Obstructive sleep apnea • Diagnosis • OSA can increase the risk of ? • Treatment Options for Sleep Apnea • Conclusion 2 3. Sleep Apnea is defined as the stopping of airflow during sleep and preventing air from entering the lungs caused by an obstruction.(1) What is Sleep Apnea? 1.British Snoring & Sleep Apnoea Association . 2. Orthodontics - Current Principles and Techniques - Graber 5th edition - 2011 Just as allergic disease significantly affects quality of life, obstructive sleep apnea, if it is untreated, may affect adversely the ability of adults and children to function adequately at work and at school.(2) 3 4. 4 5. Is Sleep Apnea Significant Health Issue ? 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed. (3) 3.American Sleep Apnea Association 4.Young et al 1993 5.Young et al 2002 15. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130: 576-84. EPIDEMIOLOGY: OSA present in 25-58% of Male and 10-37% of Female. (4)(5) According to a report by American Academy of Pediatrics, depends on the population studied, the prevalence of OSAS is in the range of 1% to 5% (15) 5 6. Types of Sleep Apnea: Obstructive sleep apnea is the most common type of sleep apnea. It occurs when the soft tissue in the back of your throat relaxes during sleep and blocks the airway, often causing you to snore loudly. 6 7. Central sleep apnea is a much less common type of sleep apnea that involves the central nervous system, occurring when the brain fails to signal the muscles that control breathing. People with central sleep apnea seldom snore. Complex sleep apnea is a combination of obstructive sleep apnea and central sleep apnea. A) Obstructive sleep apnea. Note continued chest and abdominal effort in the absence of airflow. B) Central sleep apnea. Note absence of chest and abdominal effort, as well as absence of airflow 7 8. You have a higher risk for obstructive sleep apnea if you are:  Overweight ??? (Most Important Factor) 5.Young et al 2002 6.National Institutes of Health 14.Malhotra et al 2002 • About 70% of those with OSA are obese (14) • Higher BMI associated with higher prevalence – BMI>30: 26% with AHI>15, 60% with AHI>5 – BMI>40: 33% with AHI>15, 98% with AHI>5 Obese people have extrinsic narrowing of the area surrounding collapsible region of the pharynx and regional soft tissue enlargement. Increased fat deposits posteriolateral to oropharyngeal airspace at level of soft palate, in the soft palate, and in submental area. Risk factors for Obstructive sleep apnea(6) 8 9. • Sex : Male are more likely than Female to have sleep apnea. • Age : the risk increases as you get older. • A family history of sleep apnea.

1. Sleep Apnea
Prepared by: dr. Mohamad Ghazi
1

2. Outline:
• Sleep Apnea definition
• Epidemiology
• Types of Sleep Apnea
• Risk factors for Obstructive sleep apnea
• Diagnosis
• OSA can increase the risk of ?
• Treatment Options for Sleep Apnea
• Conclusion
2

3. Sleep Apnea is defined as the stopping of airflow during sleep and
preventing air from entering the lungs caused by an obstruction.(1)
What is Sleep Apnea?
1.British Snoring & Sleep Apnoea Association .
2. Orthodontics - Current Principles and Techniques - Graber 5th edition - 2011
Just as allergic disease significantly affects quality of life, obstructive
sleep apnea, if it is untreated, may affect adversely the ability of
adults and children to function adequately at work and at school.(2)
3

4. 4

5. Is Sleep Apnea Significant Health Issue ?
22 million Americans suffer from sleep apnea, with 80 percent of the
cases of moderate and severe obstructive sleep apnea undiagnosed. (3)
3.American Sleep Apnea Association 4.Young et al 1993 5.Young et al 2002
15. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea
syndrome. Pediatrics. 2012; 130: 576-84.
EPIDEMIOLOGY:
OSA present in 25-58% of Male and 10-37% of Female. (4)(5)
According to a report by American Academy of Pediatrics,
depends on the population studied, the prevalence of OSAS is in the range of
1% to 5% (15)
5

6. Types of Sleep Apnea:
Obstructive sleep apnea is the most common type of
sleep apnea. It occurs when the soft tissue in the back of your
throat relaxes during sleep and blocks the airway, often causing
you to snore loudly.
6

7. Central sleep apnea is a much less common type of
sleep apnea that involves the central nervous system,
occurring when the brain fails to signal the muscles that
control breathing. People with central sleep apnea seldom
snore.
Complex sleep apnea is a combination of obstructive sleep
apnea and central sleep apnea.
A) Obstructive sleep
apnea. Note continued
chest and abdominal
effort in the absence
of airflow.
B) Central sleep apnea.
Note absence of chest
and abdominal effort, as
well as absence of airflow
7

8. You have a higher risk for obstructive sleep apnea if you are:
 Overweight ??? (Most Important Factor)
5.Young et al 2002 6.National Institutes of Health 14.Malhotra et al 2002
• About 70% of those with OSA are obese (14)
• Higher BMI associated with higher prevalence
– BMI>30: 26% with AHI>15, 60% with AHI>5
– BMI>40: 33% with AHI>15, 98% with AHI>5
Obese people have extrinsic narrowing of the area surrounding
collapsible region of the pharynx and regional soft tissue
enlargement.
Increased fat deposits posteriolateral to oropharyngeal airspace at
level of soft palate, in the soft palate, and in submental area.
Risk factors for Obstructive sleep apnea(6)
8

9. • Sex : Male are more likely than Female to have sleep apnea.
• Age : the risk increases as you get older.
• A family history of sleep apnea.
• People who have small airways in their noses, throats, or mouths are
more likely to have sleep apnea.
Risk factors for obstructive sleep apnea(6)
2. Orthodontics - Current Principles and Techniques - Graber 5th edition – 2011 6.National Institutes of Health
(2) 9

10.  Smokers and alcoholism
 Children might have enlarged tonsil tissues in their
throats.
Risk factors for obstructive sleep apnea(6)
6.National Institutes of Health
10

11. Craniofacial anatomy : narrow maxilla and or defection
mandible
Risk factors for obstructive sleep apnea(6)
6.National Institutes of Health 16.European journal of orthodontics 23 (2001) 703_714
Maxillary constriction may play an important role in the development of
OSA and , if so , this may have therapeutic implications. (16)
11

12. Common signs and symptoms of sleep apnea (1)
• Extremely loud heavy snoring.
• Morning headaches.
• Forgetfulness (Memory loss ).
• Excessive daytime sleepiness.
• Changes in mood or behavior.
• Anxiety or depression.
• Dry mouth or sore throat when you wake up.
1.British Snoring & Sleep Apnoea Association .
DIAGNOSIS:
Hypo-oxygenation
12

13. Radiographic Analysis
1. TGH, tongue height
2. PNSP, soft palate length
3. boundary between velopharynx
and nasopharynx
4. RPAS, retropalatal airway space
5. superior margin oropharyngeal airway space
6. PAS, posterior airway
Space
7. inferior margin oropharyngeal airway space
13

14. Required length of distraction:
Superior margin oropharyngeal
airway space
Range, 14-20 mm
average, 17.4
14

15. Diagnosis is confirmed by an overnight polysomnography
(PSG), commonly referred to as a sleep study.
This is also a requirement medico-legally to ensure that the correct
treatment is rendered. If a patient visits the orthodontist asking for an oral
appliance to alleviate snoring. (9)
• 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
very expensive
9.Presented by Harry L. Legan, D.D.S. at the PCSO Annual Session, November 15,
2008.Summarized by Dr. Shahram Nabipour, PCSO Bulletin Central Region Editor.
15

16. 6.National Institutes of Health
11.Katz ES, D’Ambrosio CM. Pediatric obstructive sleep apnea syndrome. Clin Chest Med. 2010; 31: 221-34.
OSA can increase the risk of:
About half of the people who have sleep apnea also have high blood
pressure. Sleep apnea also is linked to metabolic syndrome, diabetes, and
risk factors for stroke and heart failure.(6)
Obstructive sleep apnea syndrome (OSAS) is a common condition in children
and can result in serious neurocognitive, cardiovascular and metabolic
complications if left undetected and untreated [11].
16

17. These periods of 'stopping breathing' only become clinically significant if the
cutoff lasts for more than 10 seconds each time and occur more than 10
times every hour. (1)
1.British Snoring & Sleep Apnoea Association .
7. Harry L. Legan, D.D.S. at the PCSO Annual Session, November 15, 2008.Summarized by Dr. Shahram Nabipour,
PCSO Bulletin Central Region Editor0
Respiratory Disturbance Index (RDI)
This is a somewhat complex index that measures the number of apneic
(total cessation of breathing) and hypopnea (shallow breathing) events per
hour of REM and non REM sleep.
For example, someone who has an
RDI of 30 has 30 apneic or hypopnea events an hour.
The range of RDIs is as follows: RDI < 5 Normal; RDI 5-15 Mild;
RDI 15-30 Moderate; RDI > 30 Severe.(7)
When Sleep Apnea Considered Clinically Significant ?
17

18.  Self-help Treatment options for sleep apnea.
 Using Orthodontic Appliance.
 Continuous positive airway pressure (CPAP) devises.
 Surgical Treatments for Sleep Apnea.
Treatment Options for Sleep Apnea
18

19. Self-help treatment options for sleep apnea
• Weight loss
• Quitting smoking.
• Avoiding alcohol, sleeping pills, and sedatives,
especially before bedtime as they relax the muscles
in the throat and interfere with breathing.
• Maintaining regular sleep hours.
• Sleep on your side. Avoid sleeping on your back
• Prop your head up.
• Maintain open nasal passages. Try to keep your nasal
passages open at night using a nasal dilator, saline
spray.
19

20. PALATAL EXPANSION
•CREATES MORE SPACE IN THE MOUTH FOR THE TONGUE
•FACILITATES POSITIONING THE TONGUE ANTERIORLY AND
IN THE ROOF OF THE MOUTH
•WIDENS THE NASAL PASSAGE & FACILITATES NASAL
BREATHING (ROOF OF THE MOUTH IS THE FLOOR OF THE NOSE)
Orthodontic Appliance
narrow maxilla can be reason for OSA manly in pediatric
In preschool children with narrow maxilla get benefit from RPE to
treatment OSA (17)
17. Eur J Paediatr Dent. 2012 Mar;13(1):57-63. 20

21. 21

22. 22

23. 23

24. Orthodontic Appliance
Tongue repositioning device
A study in the Oct. 15 issue of the Journal of Clinical Sleep Medicine (JCSM)
found that tongue retaining devices (TRD) performed similarly to
mandibular advancement devices (MAD) in OSA patients.(12)
Tongue retaining devices
12.The American Academy of Dental Sleep Medicine (AADSM) 24

25. Tongue repositioning devices include the TRD, which is the best studied
of these devices. The TRD is a custom-made soft acrylic appliance that
covers the upper and lower teeth and has an anterior plastic bulb. It uses
negative suction pressure to hold the tongue in
a forward position inside the bulb. (13)
13. K.A. Ferguson / Clin Chest Med 24 (2003) 355–364 25

26. The Nocturnal Airway Patency Appliance (NAPA) Appliance
Orthodontic Appliance
The NAPA appliance has been in use since 1983 and ranks as the oldest
appliance in continuous use.
The extension in front is a breathing tube which keeps the lips apart.
Over the years, it was found that this arrangement was unnecessary
since patients tend to breathe through their noses when asleep and block the
breathing tube with their tongue. However, many patients like the security
of an airway which is always open and unobstructed.
26

27. Orthodontic Appliance
Mandibular repositioning devices
27

28. 28

29. Orthodontic Appliance
Mandibular repositioning devices
Reductions from 16.3 to 11.7 in AI and from 5.7 to 3.8 in AI were
observed after MAD use. (18)
Treatment with oral appliances, i.e., MADs, can be an effective alternative for
mild and medium-to-moderate OSA, but requires strict
monitoring due to differences in individual response to this therapy. (18)
18.Progress in Orthodontics 2013, 14:10 doi:10.1186/2196-1042-14-10
29

30. Continuous positive airway pressure (CPAP)
30

31.  Nasal surgery, including turbinectomy (removal or reduction of a
nasal turbinate ), or straightening of the nasal septum
Tonsillectomy and/or adenoidectomy
Surgical Treatments for Sleep Apnea.
31

32. 32

33.  Removal or reduction of parts of the soft palate and some or
all of the uvula such as uvulopalatopharyngoplasty (UPPP)
 Genioglossus Advancement
 Maxillomandibular advancement
33

34. Conclusion
Obstructive Sleep apnea have high prevalence
rate.
The main Challenge in sleep apnea is not the
treatment but it is the diagnosis .
If you treat patient with sleep apnea acutely you
will give him better quality of life.
34

35. References:
1.British Snoring & Sleep Apnoea Association http://www.britishsnoring.co.uk
2. Orthodontics - Current Principles and Techniques - Graber 5th edition - 2011
3.American Sleep Apnea Association http://www.sleepapnea.org/i-am-a-health-care-
professional.html
4.Young et al 1993.
5.Young et al 2002.
6.National Institutes of Health https://www.nhlbi.nih.gov/health/health-
7. Harry L. Legan, D.D.S. at the PCSO Annual Session, November 15, 2008.Summarized by Dr.
Shahram Nabipour, PCSO Bulletin Central Region
topics/topics/sleepapnea/atrisk.html#
8.Sleep Medicine by Dr. Christian Guilleminault.
9.Presented by Harry L. Legan, D.D.S. at the PCSO Annual Session, November 15,
2008.Summarized by Dr. Shahram Nabipour, PCSO Bulletin Central Region Editor.
10.Denton Sleep Disorders Center www.dentonsleepdisorderlab.com
11.Katz ES, D’Ambrosio CM. Pediatric obstructive sleep apnea syndrome. Clin Chest Med. 2010;
31: 221-34.
12.The American Academy of Dental Sleep Medicine (AADSM)
13. K.A. Ferguson / Clin Chest Med 24 (2003) 355–364
14.Malhotra et al 2002
15. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and
management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130: 576-84.
16.European journal of orthodontics 23 (2001) 703_714
17. Eur J Paediatr Dent. 2012 Mar;13(1):57-63.
35

36. 36