Obtrustive sleep apnea.pptx

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.
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

1. Obstructive Sleep Apnea (OSA) Presented by: Dr. Hiral Joshi 3 rd 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 , 6 th 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 , 6 th edition

7. AASM 2009

8. 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)

9. 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.

10. 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

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

12. 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

13. 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%)

14. 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): 5 to 15 is considered mild; 15 to 30 is considered moderate; More than 30 is considered severe.

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

16. 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.

17. 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

18. 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.

19. 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

20. Pathophysiology

21. 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  

22. 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.

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

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

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

26. 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

27. Questionnaire used: NoSAS score Epworth sleepiness scale STOP BANG questionnaire Berlin questionnaire

28. 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.

29. 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.

30. 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

31. 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

32. 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) 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) 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

33. 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) 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) 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

34. 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

35. There are three primary types of PAP modes: Continuous positive airway pressure (CPAP), Bilevel positive airway pressure ( BiPAP ) 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

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

37. 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

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

39. 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.

40. 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.

41. 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

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

43. 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.

44. 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

45. 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

46. 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)

47. 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.

48. 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

49. References Essentials of physiology - K .Sembulingum , 6 th edition Textbook of medical physiology – Guyton and Hall – 2 nd 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

50. 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

51. 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

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