D D Sleep Disordered Breathing and Dentistry Sleep Disordered Breathing and Dentistry National Primary Oral Health Care Conference August 9, 2005 Atlanta, Georgia

D D Oral cavity Tongue3Uvula Nasal cavity PharynxGenioglossus Tensor Veli *Soft tissue tube Anatomy of Upper Airway

D D Physiology of Snoring Mandible back Tongue back Partial closure upper airway space Speed airflow increases Vibration of uvula * Other cause???

D D Snoring Demographics z % over 50 years snore z Males twice as likely as females z Overweight / neck size z Males 17” or greater z Females 16” or greater

D D Snoring Significance z Snorers awaken their partners and occasionally themselves by the loudness of their snoring resulting in loss of sleep (to be discussed later) z % have a Severe Upper Airway Sleep Disorder!

D D Severe Upper Airway Sleep Disorders Upper Airway Resistant Syndrome (Tx – Same as OSA) Obstructive Sleep Apnea (OSA)

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D D Obstructive Sleep Apnea z Complete or almost complete reduction in airflow through the upper airway lasting for more than 10 seconds, resulting in severe oxygen depletion leading to medical problems z Causes - Tongue, obesity, inflammation of any soft tissues in the upper airway (tonsils, adenoids), polyps, tumors, etc z Demographics - 4% of adult middle-aged males and 2% of females

D D Physiology of OSA Loss of muscle activity Mandible/ Tongue back Partial/total closure airway Decreased oxygen to lungs Blood oxygen desaturation

D D Patients With OSA z Snore loudly z Stop breathing - snort to start again z Choke z Suffer from acid reflux z Toss and turn z Wake up frequently z Daytime sleepines

D D Significance of OSA z Loss of air to lungs may happen many times per hour z Blood oxygen drops below the 90% level causing the patient to arouse to breath z Arousal causes loss of sleep, daytime sleepiness, decreased production, increased accidents, etc. z May cause medical problems ranging from mild to “life threatening”

D D Medical Responsibility z Diagnosis and determine presence and severity of an UASD - “Sleep Study” z Determine treatment z Treat patient or refer for oral device Dental Responsibility z Recognize and refer z Provide support when requested

D D Physician Treatment Options z Behavior modification z Surgery z Medications z CPAP z Oral devices

D D Behavior Modification z Sleep on side rather than back z Avoid alcohol late in day and evening (CNS Depressant) z Minimize use of sedatives z Weight loss Long term success poorly documented

D D Surgical Procedures z UPPP - UvuloPalatoPharyngoPlasty z LAUP - Laser-Assisted Uvula- Palatoplasty z High Frequency Radio Waves to uvula z Tonsillectomy, adenoidectomy z Tracheostomy - life saving procedure z Craniofacial operations - Maxillomandibular Advancement, Hyoid lift

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D D z The most effective acceptable surgical treatment of OSA (excluding tracheostomy) z Success rates of 96%, 97%, 98% and 100% reported in the literature z Caution – Reports of devitalization of teeth cause by surgical procedures Maxillomandibular Advancement (MMA) Prinsell JR. Maxillomandibular advancement (MMA) in a Site- Specific treatment approach for obstructive sleep apnea: A surgical approach. Sleep Breath. 2000;4:

D D Continuous Positive Air Pressure - CPAP z Most effective of all treatment modalities z Patient must wear mask while sleeping z Very noisy equipment, uncomfortable z Equipment not easily portable z Compliance poor

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D D MedicationsMedications z Only for those patient who are not good candidates for CPAP, Oral Devices or Surgical Procedures z Should not be considered by dentistry

D D Oral Device How and What

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D D z Snoring/OSA caused by loss of airway space z Most oral devices advance the mandible z This pulls the genioglossus forward z This pulls the tongue forward z Upper airway space is regained z Snoring/OSA diminished or eliminated z Others simply keep the tongue protruded How Does An Oral Device Work?

D D All Dental Patients Should be Evaluated for a Potential Sleep Disorder

D D Diagnosing Snoring / OSA z Medical history z Sleep history z Extended dental examination including TMJ evaluation z Epworth Sleepiness Scale z Preliminary diagnosis z Referral for medical evaluation (sleep study)

D D z Snore loudly z Stop breathing - snort to start again z Choke z Suffer from acid reflux z Toss and turn during sleep z Wake up frequently z Have daytime sleepiness Quality of Sleep Questions

D D 1. Weight Compared to Year Ago? 2. Ever Treated for Nasal Congestion 3. Neck Circumference 4. Alcohol/Sedatives- How Often? 5. Tired/Sleepy During the Day? 6. Sleep Position - Back, sides, stomach Questions I’ll Ask

D D 6.Frequency and loudness of snoring 7.Previous Sleep Studies or Past Treatment for Snore Problems? 8.Do You Ever Awaken Gasping for Air? 9.Ever Been Told That You Stop Breathing While You Sleep? Questions I’ll Ask

D D How much air space is present? z Open fairly wide and slightly protrude your tongue z Grade - I, II, or III (Jamieson AO, Becker PM. Snoring: its evaluation and treatment. Hospital Medicine. March 1996)

D D Grade I The tonsillar pillars, soft palate, and uvula can be seen, with at least 5 mm between the tip of the uvula and the base of the tongue

D D Grade II Tonsillar pillars and soft palate remain visible, tip of the uvula is obscured by the base of the tongue: part of the free edge of the soft palate is still visible

D D Grade III Only the soft palate can be seen

D D Epworth Sleepiness Scale z Likeliness to doze off or fall asleep in certain situations versus to just feeling tired z Use the following scale to choose the most appropriate number for each situation: z Likeliness to doze off or fall asleep in certain situations versus to just feeling tired z 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

D D Preliminary Diagnosis z Snoring only z Snoring and potential upper airway sleep disorder z Definite disorder – OSA or UARS

D D Oral Devices for Treating Snoring and Obstructive Sleep Apnea

D D Oral Devices Indications Recommended for snoring and mild to moderate sleep apnea if CPAP unsuccessful. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral devices. An American Sleep Disorders Association Report. Sleep. 1995;18(6):511-13

D D Problems with MADs after long term use (3 years or more) z Minor jaw/facial, tooth, muscle pain – 40% z Xerstomia – 30% z Very Satisfied – 82% z Satisfied – 15% z Painless but irreversible change in occlusion - 26% GT, Sohn JW, Hong CN. Treating obstructive sleep apnea and snoring: assessment of an anterior mandibular positioning device. J Am Dent Assoc. 2000;131:

D D CLINICAL IMPLICATIONS z Patients with mild-to-moderate OSA who receive a two-piece, adjustable MAD should be informed that 50 percent of patients quit using the device in a three-year period and some will experience shifts in their occlusion.

D D Device Treatment Options Tongue Retaining Device (TRD) Mandibular Advancement Device (MAD)

D D Tongue Retaining Device (TRD) Laboratory fee - $150

D D Indications for TRDs z Edentulous patients z Patients with potential temporomandibular joint problems Problems with TRDs z Sore tongue z Tongue elongation

D D Tongue Retaining Device

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D D TRD Findings z Altered the timing of the inspiratory genioglossus (GG) activity and the onset of inspiration effort z Oxygen desaturation index dropped to fewer than 10 events/ h in 75% of patients z Significantly improved the blood oxygen saturation level in infants z Helped patients with mild to moderate OSA; however, patients with more severe OSA may also be treated effectively

D D Mandibular Advancement Devices zFixed - $ zAdjustable - $

D D Fabrication of an “Adjustable” Laboratory Fabricated Device

D D Practice CR to maximum protruded position

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D D Patient closing in the pre-selectedprotrudedposition

D D An interocclusal recording is made using the wax matrix

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D D Adjustment of the device must be made depending on device fabricated

D D Patient instructions for adjustment (depends on device but typical): z No adjust for first 3 nights to allow patient to become accustom to device z Protrude device 0.25 mm per night for 3 – 4 nights, stop, check for improvement z Continue until symptoms are relieved or reduced or TMJ symptoms develop

D D EvaluationEvaluation z Following relief of symptoms allow patient to wear device for 2 – 4 weeks z Have patient wear a Pulse Oximetry device and determine success of treatment z Continue adjustments and followup Pulse Oximetry or z Refer to Physician for reevaluation (2 nd polysomnography)

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D D Patient Should Expect z Lips will be very dry - lip balm z Difficulty going to sleep for a few nights z Lots of saliva - on pillow z Teeth may become sensitive - seek care immediately - usually slight adjustment

D D z For approximately 20 minutes upon awakening teeth will not close together - don’t force closure - no treatment z TMJ discomfort - May be sore for a few minutes during early adjustment, must be relieved by moving mandible posteriorly Patient Should Expect

D D z Device for treatment of snoring and/or OSA z Cease wearing and return to dentist immediately if any problems develop z Device may only be partially successful z May cause existing dental restorations to loosened or fail z Device may increase severity of an existing OSA Consent Form Before Treating

D D Is Insurance Coverage Available? Yes and No z Yes - medical insurance coverage is possible for treatment of a diagnosed sleep apnea condition. Very hard to collect z No - medical insurance coverage for a snoring only problem z No - dental insurance coverage for either

D D Treating OSA with Oral Devices MD exam$100 – 500 Initial Sleep Study$900 – 1800 Device and Follow-up$800 – 2000 Pulse Oximetry $35 – 200 Repeat Sleep Study$900 – 1800 Total $2735 – 6300

D D Sleep Disorders in Infants and Children

D D Prevalence in Infants and Children z 3 – 12% snore z 1 – 10% have OSA When do problems occur z Snoring – 22.7 months z Apnea – 34.7 months

D D Symptoms OSA children exhibited : z Chronic mouth breathing (84%) z Otitis media (middle ear infection) (64%) z Sinusitis (56%) z Sore throat (51%) z Choking (47%) z Daytime drowsiness (42%) z Less observed symptoms included poor school performance, enuresis (bed wetting), poor appetite and/or weight gain, dysphagia, and vomiting.

D D What Do Studies Show? z 7% of the children were habitual snorers and exhibited a higher prevalence of difficulty in breathing, observed apneas, restless sleep, and nocturnal enuresis than non-snorers z Subjects were more likely to fall asleep while watching television and in public places and were hyperactive

D D z The presence of asthma and hay fever increased the likelihood of habitual snoring with exposure to cigarette smoking at home z Primary snoring was corrected with adenotonsillectomy resulting in weight gain and a restoration of normal growth z 26% of children with mild symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) also demonstrate OSA as observed during polysomnography testing

D D z Almost 25% of OSA children had clinically significant behavioral sleep problems such as sleep walking and nightmares as well as a greater incidence of daytime externalizing behavior problems z Children 11 to14 years of age who were diagnosed as being sleep deficient exhibited lowered self-esteem, significantly lower grades and higher levels of depressive symptoms than those students registering more normal sleep duration

D D z The early onset of alcohol, marijuana or illicit drug use by the adolescent as well as an early onset of cigarette use by the age of 12 to 14 could be significantly predicted by the mother’s ratings of their children’s sleep problems at ages 3 to 5 years z Children with sleep disorders and attention deficit hyperactivity disorder had a verbal IQ (intelligence quotient) up to 20 points lower than control subjects

D D z Children with lower academic performance in middle school were more likely to have snored in early childhood and have required tonsillectomy and adenoidectomy z Persistent sleep disturbance is likely to adversely affect cognition, mood, behavior and family function

D D z Habitual snoring was significantly associated with lowered academic performances in mathematics, science and spelling in third grade children z Infantile OSAS does occur in infants due to hypertrophic adenoids and tonsils and that among other things these infants failed to gain weight

D D RecognitionRecognition z Of all observations made by parents, that of “snoring every night”, is the most significant factor in predicting OSA z Children with sleep breathing disorders had the dolico facial pattern (disproportionately long face) z Migraine headaches may be indicative of sleep disturbances

D D Risk Factors for sleep apnea in children include: z Obesity z African-American race z Sinus problems z Persistent wheezing

D D Guideline for Diagnosis of OSAS 1. All children should be screened for snoring 2. Complex high-risk patients should be referred to a specialist 3. Patients with cardiorespiratory failure cannot await elective evaluation 4. Diagnostic evaluation is useful in discriminating between primary snoring and OSAS, the gold standard being polysomnography

D D 5. Adenotonsillectomy is the first line of treatment for most children, and continuous positive airway pressure is an option for those who are not candidates for surgery or do not respond to surgery 6. Patients should be reevaluated postoperatively to determine whether additional treatment is required Guideline for Diagnosis of OSAS

D D TreatmentTreatment z Children with OSA have marked increases in healthcare-related costs z If prompt diagnosis and management are not implemented some of these complications may not be completely reversible, resulting in long- lasting consequences z Adenotonsillectomy is the treatment of choice for most children and continuous positive airway pressure may be an option for those patients who are not a candidate for surgery or who do not respond to surgery

D D z Caregivers detected a long-term improvement in quality of life following adenotonsillectomy for OSA although the results were not uniform z Decreasing nasal congestion associated with allergic rhinitis can improve sleep in these patients and lead to improved daytime quality of life z CPAP can be effectively used in children less than 2 years of age TreatmentTreatment

D D z Children with primary snoring were unlikely to develop polysomnography-confirmed OSA and therefore delayed treatment was safe z For patients with residual problems following adenotonsillectomy, collaboration with orthodontists to improve craniofacial risk factors should be considered TreatmentTreatment

D D SummarySummary z Failure to diagnose and treat these patients can result in serious but usually reversible problems which may include impaired growth, neurocognitive and behavioral dysfunction and cardiorespiratory failure z Identifying these patients may be difficult because they may not exhibit signs or symptoms while awake

D D One Westbrook Corporate Center Suite 920 Westchester, IL (708) Annual Membership$295 Quarterly - “ADSM Report” Quarterly – “Sleep and Breathing” www. dentalsleepmed.org Academy of Dental Sleep Medicine