Achieving healthy and effective sleep for you and your family
Continue reading “Are you tired, fatigued or sleepy – how’s your sleep?”
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.
Sleep-disordered breathing (SDB) affects adults and children worldwide and previous studies (HypnoLaus study), which found rates of 49.7% for men and 23% for women.
This is huge. A 2019 U.S. paediatric study reported that an estimated 1% to 5% of children have sleep-disordered breathing related to obstructive sleep apnea, with a smaller proportion of children having central or mixed sleep apnea and goes on to state the benefits of screening, diagnosis and treatment.
In my opinion, this group (children) are both the group that when treated would have the greatest long-term benefit to society, yet are also amongst the worst served groups.
It is estimated that approximately 23 million adults in the United States alone have undiagnosed or untreated moderate to severe obstructive sleep apnea (OSA), basically road accidents (2-10% increase), emergency or hospital care, and the enormous financial burden on healthcare resources.
The same is certainly true in Canada and the UK where just like the US, the present government quietly pass the problem to the next government while the patients simply continue to enjoy their increased morbidity and mortality.
The main problem in patients with SDB/OSA is the pharyngeal or upper airway collapse occurring in hypopnea (partial closure following collapse and reduction in ventilation) or apnea (complete respiratory cessation).
According to the famous researchers Guillerminault and Huang “the upper airway is a collapsible tube, and its collapsibility increases during sleep”. That is the crux of the problem. Our increasing weight as a population, merely worsens the outlook.
The increased levels of carbon dioxide (hypercapnia) and the low concentration of oxygen (hypoxia) in the blood in these patients may lead to hypertension, cardiac diseases, and even premature death.
Other issues including snoring, mood disorder, disruptive, and depletion of quality of life are associated.
Some oral anatomic features associated with SDB may include high arched or narrow hard palate and retrognathia. This is both a cause and an effect.
The most common risk factor for sleep apnea in children is the airway constriction associated with enlarged tonsils and/or adenoids.
Additionally, the atypical jaw and facial growing pattern of what’s referred to “adenoid facies” has been associated with SDB, and may lead to a reduced size of the upper airway; causing not just sleep breathing-related problems but also a constricted maxilla, usually causing posterior cross-bites and crowded teeth.
Impaired growth, cardiovascular problems, and learning and behavioral problems are also linked to SDB, because these problems are critical and are related to craniofacial proportions, the dentist is the first person to recognize these issues.
The approach most often indicated to treat SDB in adults is the oral appliance (OA). The OA can be categorized into two types, mandibular advancement device (MAD) which aims to protrude the mandible and associated soft tissues to open the airway and reduce the apnea-hypopnea index (AHI).
This is the measure most commonly used to determine success (airway compromise per hour).
The less frequently used tongue retaining device where the objective is to maintain the tongue in a forward position, to avoid obstruction of the airway may also be used, but is more frequently retained for those without teeth as the others require teeth to hold the jaw.
However, continuous positive airway pressure (CPAP) therapy is mostly used by sleep physicians as the gold standard for OSA management because it almost always works if the patient can tolerate it.
Oral appliances exist because many people cannot tolerate CPAP, and many choose not to. Alas, many times those patients are often offered no alternatives due to ignorance, arrogance or financial incentive.
For years, many studies reported upper airway dimensional changes and AHI decrease in children and adolescents with posterior cross-bites (upper teeth biting outside the lowers) and/or maxillary constriction (narrow dental arch) and retrognathia (lower jaw anatomically further back than the upper, treated for maxillary expansion and mandibular advancement, respectively.
In general, those studies, have encountered positive results in regard to an increase in upper airway dimension and breathing capacity. An increase in the upper arch width (rapid maxillary expansion) has been shown to be a worthwhile procedure WHEN indicated, just as has Adeno-tonsillectomy.
Although it is evident that dentists have an important role related to SDB/OSA, the exact position of the dentist in the overall evaluation and treatment paradigm for patients with SDB/OSA continues to be debated. It will be for the individuals to determine how we’re seen as a whole.
The objective of this systematic review was to summarize existing guidelines, recommendations, and studies designed with the intention to describe and guide the role of dentists in SDB related issues.
SDB: sleep-disordered breathing. This is the syndrome of signs and symptoms of airway compromise during sleep. This includes snoring, obstructive sleep apnea (mild, moderate and severe) and UARS – upper airway resistance syndrome.
OSA: obstructive sleep apnea. The disease of airway closure (part or full) during the night caused by an obstruction.
OAT: oral appliance therapy. A dental appliance constructed to maintain an open airway by either, or both jaw repositioning and airway protection from the tongue.
MAD: mandibular advancement device. An oral appliance which repositions the jaw relationship (lower to upper) thereby protecting the airway from intrusion of the tongue. It may be seen as a ‘mechanical stent” to keep the airway patent.
AHI: apnea-hypopnea index. The combination of partial and complete airway closures per hour from which the diagnosis and management success is determined.
CPAP: continuous positive airway pressure. This is a means of delivering room air (often humidified) at pressure. It is generally composed of a bedside pump, hose and face mask. It may be seen as a ‘pneumatic stent” to keep the airway patent.
AADSM: American Academy of Dental Sleep Medicine. The largest association of dentists with a special interest in dental sleep medicine. Examinations are available for advancement.
RDI: respiratory disturbance index or respiratory distress Index — is a formula used in reporting polysomnography (sleep study) findings. Like the apnea-hypopnea index (AHI), it reports on respiratory events during sleep, but unlike the AHI, it also includes respiratory-effort related arousals (RERAs).
RDI is calculated as the number of apnea events/hour plus the number of hypopnea events/hour plus the number of respiratory-effort related arousals (RERAs) per hour of sleep.
UARS: Upper airway resistance syndrome – see UARS article.