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hygiene - the international C.E. magazine of dental hygiene

20 I I C.E. article_ sleep apnea _What to look for Magliocasays,“ThepopulationwithOSASisahet- erogeneousgroup,andhaveawiderangeofphysical attributes.NotallpatientswithOSAShaveallofthese physical features.”7 The most common orofacial characteristics encountered include a retrognathic mandible, narrow palate, large neck circumference, longsoftpalate(whichleadstodentistsbeingunable to visualize the entire length of the uvula when the patient’s mouth is open wide), tonsillar hypertrophy, deviated nasal septum and relative macroglossia. _Potential outcomes of non-treatment Patients with OSAS have interrupted sleep pat- terns because the obstruction of airflow causes prolongedinterruptionsintheirbreathingwhilethey sleep (up to 40 seconds). Because the condition can lead to a reduction of oxygen in the blood stream, a host of medical complications can occur. Individuals with obstructive sleep apnea can experience wors- ening snoring, which is caused by vibration of the partially collapsed soft palate as air passes. Respira- toryevents,whichdepletecertainstagesofnon-REM and REM sleep, contribute to sleep fragmentation andunrefreshingsleep.7 Becauseofthelackofsleep, an OSAS sufferer may have difficulty concentrating and staying awake during the day. When sufferers sleep on their back, gravity pulls the jaw and tongue down and back. This causes the mouth to open and the tongue to drop back into the airway, narrowing the air passage. _Treatments Oral devices and surgical intervention are the proceduresusedtotreatOSAS.Anoralappliance(Fig. 4)isasmallacrylicdevicethatfitsovertheupperand lower teeth or tongue (similar to an orthodontic re- tainerormouthguard).Thisdeviceslightlyadvances thelowerjawortongue,whichmovesthebaseofthe tongue forward and opens the airway. This improves breathingandreducessnoringandapnea.Theappli- ance is fabricated and customized for each patient by a dentist experienced in the treatment of snoring andsleepapnea.Theappliancesarecomfortableand well tolerated by patients. Appliances are easy to place and remove, easy to clean and are convenient for travel. _Non-surgical treatments are available, including positional therapy The two main categories of oral appliances currently in use are the mandibular advancement devices (MAD) and the tongue retaining devices (TRD). The mandibular advancement devices, made of acrylic materials, are custom fabricated for each patient. The impression for the acrylic devices can be made in the dental office for lab fabrication. The devices fit comfortably over the upper and lower teeth, positioning the lower jaw slightly forward, advancing the tongue and soft tissues of the throat to open the airway. Some of the “repositioners are designed to hold the mandible anteriorinferiorly, constructedtopositionthemandibleat75percentof themaximalmandibularadvancementandwithina7 mmopeningbetweenupperandlowerincisors”8 with no adverse effects to the temporal mandibular joint. The MADs have an adjustment mechanism built into the device, enabling users to gradually change thepositionofthebottomjawunderdentalsupervi- sion to improve the effectiveness of the device. Oral appliances used for OSAS patients cause a “mandibular advancement, including development of posterior open bite, altered inclination of incisors and decreased anterior open bite.”8 Through the use of various imaging techniques, research on appli- ances used for OSAS has identified various dental/ skeletal changes that occur. One of the most common effects, referenced in manystudies,isthedegreeofverticalandhorizontal overlap of the teeth (overjet and overbite, respec- tively).9 Theadjustmentmechanismmakesitpossible to position the device to best address a patient’s particular needs. The tongue-retaining device is custom-made us- ingasofter,pliablematerialwithacompartmentthat fits around the tongue to hold it forward by means of suction. This device is used most for patients with denturesorpatientswhocannotadequatelyadvance theirlowerjaw.Suchpatientsmustbeabletobreathe well through their nose, or they may have difficulty tolerating this appliance. hygiene 1_2012 Fig. 4 Fig. 4_One of many oral devices used to relieve sleep apnea. The appliance keeps the mandible in a static position to not fall back when the individual is sleeping in a supine position. (Photo/Provided by Respire Medical/The Respire Blue Series)