Achieving healthy and effective sleep for you and your family
Causes of bipolar disorder are not yet known. Research is beginning to consider the possible involvement of seep in causation as well as effect.
Continue reading “How are Sleep and Bipolar Disorder associated? 1”
The severity of OSA is classified as mild (5-14 AHI); moderate (15-30 AHI), and severe (+30 AHI). However, for children the threshold is lower: mild (1-5 AHI), moderate (5-10 AHI), and severe (+10 AHI).
This infers that 0-5 is insignificant in an adult, yet not a child, we have no evidence (except anecdotal) for this and low levels of AHI may be associated with snoring which when heavy and chronic has shown itself a significant co-factor in stroke.
Usually, the reduction in the AHI, respiratory disturbance index, and respiratory event index must be less than 5 and greater than 50% reduction in these indexes to be classified as successful in the management of the disease, but again must be reviewed in light of the individual.
What would you do for someone who had severe OSA with an AHI of 60, when they either cannot or will not wear CPAP? They subsequently find OAT successful in that they wear it happily and long-term and find improvements in may symptoms.
Measurement shows significant improvement in measurements including a reduction of AHI down to (only) 16. Is that a success?
Snoring patients without features of OSA should undergo treatment to reduce snoring to a subjective reasonable level. With little mention in the study, there is widespread belief that snoring, even heavy, is OK except for domestic disharmony. This is not what investigation shows.
Age 12 years is the cutoff point for childhood SDB. This is completely arbitrary and added as an after thought. The adult ranges have already changed once so this must still be seen as a practical work in progress.
A definition given by the AADSM in 2008 states that the dentists’ role in dental sleep medicine “focuses on the management of sleep-related breathing disorders (SDB), which includes snoring and obstructive sleep apnea (OSA), with oral appliance therapy (OAT) and upper airway surgery.”
With a broader definition, it has been proposed “Dental Sleep Medicine is the discipline concerned with the study of the oral and maxillofacial causes and consequences of sleep-related problems.”
This study reports that from this perspective, the role of dentists would go farther, including the management of orofacial pain, oral moistening disorders (including oral dryness and hypersalivation), gastro-esophageal reflux disorder (GERD), SDB (including snoring and OSA), and mandibular movement disorders (including dyskinesia, dystonia, and sleep bruxism).
According to the studies included in this systematic review, screening SDB, OA treatment, and follow-up are the major roles for dentists working in dental sleep medicine.
In future posts we can deal with the other aspects of this review, namely, screening, treatment and follow up. This is far from the only study but was chosen as it covered the aspects adequately.
Incidentally, as obstructive sleep apnea (OSA) is an increasing problem worldwide a large number of patients may remain undiagnosed.
Dentists could suspect OSA, but little is known about their knowledge and attitudes towards the topic. An email questionnaire was sent to dentists working in Helsinki Health Centre, Helsinki, Finland. It consisted of demographic data, items on dentists’ overall knowledge of OSA and factors associated with it, and their possibilities and willingness to take part in the recognition and treatment of OSA patients.
The study found that dentists could play an important role in suspecting OSA, but they may need more education to cope with that.
Overall 1,432 studies were found in the six databases searched. In the second phase, 231 studies were evaluated by reading their full text. Eighteen studies matched the inclusion criteria. The experts, for a total of 22 included studies, included four studies.
The selected studies were published between 1999 and 2019. Recommendations made by the studies included in this systematic review were for the dentists’ clinical practice in patients with OSA, SDB or snoring.
Most of the included studies were based on or were the guideline itself from an accredited dental or medical association as follows: American Association of Orthodontics, American Academy of Dental Sleep Medicine, and American Academy of Sleep Medicine
Screening could include questionnaires, such as the validated tool for OSA risk assessment STOP-Bang questionnaire, the Epworth Sleepiness Scale, Friedman Tongue Classification System, Kushida Index, or Berlin Questionnaire for Sleep Apnea; evaluation of neck size and body mass index; modified Mallampati classification (throat size) to describe the patency of oral airway.
Dentists should refer to the sleep physician or otolaryngologist when SDB/OSA is suspected.
Recommendations for OSA Management oral appliances.
Oral Appliance Therapy can be an effective therapy for OSA.
OAT is indicated for patients with mild to moderate OSA who prefer OAs to CPAP therapy or who do not respond to CPAP therapy or have contraindications for the use of CPAP therapy, although the sleep physicians are ‘responsible’ for prescribing the most appropriate or acceptable treatment option.
OA can significantly decrease the AHI, respiratory disturbance index, and respiratory event index, independently of OSA severity.
Reduction in AHI before and after treatment with O.As versus CPAP has no statistically significant differences
The sleep physician should prescribe OAT rather than no treatment for adult patients who request treatment of primary snoring and also for patients with OSA who do not tolerate CPAP therapy.
The sleep physician with sleep testing should do the evaluation of OA treatment efficacy so that a comparison from before and after can be compared.
Studies’ recommendations for the management/treatment of SDB by qualified dentists is that only qualified dentists should manage SDB/OSA and snoring screening and therapy.
When OAT is prescribed, the qualified dentist should use a custom, titratable appliance over non-custom oral devices.
The dentist should instruct patients with OA to return for follow-up, and evaluate possible dental-related side effects such as occlusal (bite) changes and long-term effects.
The dentist can acquire objective information with a portable monitor for purposes of titration only; the diagnosis and follow-up assessment are the sleep physician’s role.
Studies’ recommendations for multidisciplinary approach:
A physician or sleep physician should make the final diagnosis of SDB or OSA.
The sleep physician with sleep testing should do the evaluation of OA treatment efficacy.
The dentist must collaborate with the surgeon in case of maxillofacial surgery.
Two orthodontic treatments in children may change airway dimension: rapid maxillary expansion in patients with a constricted maxilla and mandibular advancement for class II malocclusion correction; however, the orthodontic treatment in children in whom OSA is diagnosed should be planned based on the same principles for correction of dental and skeletal malocclusion.
The management of OSA in children is different from that in adults, with tonsillectomy and adenoidectomy usually considered the first-line treatment.
Multidisciplinary teamwork is indispensable. In my opinion this indicates the “range” over which the disease is found and managed is wide, consequently, a “cook-book” approach may not always be the best approach.