Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-03-23, 14:15:30 | version 1.38.0
8 Dental Tribune Middle East & Africa Edition | July-August 2015mCME The role of the dental team in the management of the patient with sleep apnea mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 2 CME Credit Hours DHA awarded this program for 2 CPD Credit Points CAPPmea designates this activity for2continuingeducationcredits. By Nancy M. Costa-Larson, USA T he evolution of the den- tal hygienist’s role in the assessment of a client’s oral health from a singular ap- proach to a collaborative multi- disciplinary approach is evident in the treatment of clients with sleep disorders. Knowledge of the variations in sleep disorders, medications, treatment needed, as well as the various appliances will be vital to the dental health- care providers. Pagel (2012) says that by 2015, 40 percent of the U.S. population will have some form of sleep disorder; 18 mil- lion Americans have sleep ap- nea, which affects all ages, both sexes and may be genetic. The most prevalent form occurs in 4 percent of middle-aged men and 2 percent of middle-aged women.1 As with all medical conditions, early detection and baseline data will aid in monitoring changes in the patient’s health and providing useful informa- tion in treatment planning and implementation. Sleep apnea in the past has been viewed as most typically related to snor- ing; however, there are different types of sleep apnea disorder. The most prevalent and known is obstructive sleep apnea syn- drome. Another type, central sleep apnea, is less common. A third type, complex sleep apnea, combines both the obstructive and central types. What is obstructive sleep ap- nea syndrome? Obstructive sleep apnea syn- drome (OSAS) is a common, but underdiagnosed disorder that is potentially fatal.3 According to de Almeida et al. (2006), “It happens most frequently dur- ing REM sleep, and breathing stops for 10 to 30 seconds, which re-sults in reduced levels of oxygen dissolved in the blood.”4 The patient with the OSAS does not know this is happening. A person’s quality and quantity of sleep is often inadequate. These interruptions of sleep can affect a person’s mental and physi-cal state — and lead to additional problems in the oral cavity. What is central sleep apnea? Central sleep apnea is caused by the brain failing to signal the breathing-control muscles to work. With central sleep apnea, snoring is infrequent to rare because there is no airway ob- struction. Though this disorder is less common than obstructive sleep apnea, it is important to address for the overall health of the sleeper. Oral appliances do not work in this situation. Cen- tral sleep apnea is diagnosed by sleep studies and typically treat- ed with medications. What is complex sleep apnea? Complex sleep apnea is a com- bination of obstructive sleep apnea and central sleep apnea. Some patients with obstructive sleep apnea develop central sleep apnea while on treatment with continuous positive airway pressure (CPAP).”2 This article focuses on obstruc- tive sleep apnea and how it re- lates to the oral cavity. Cause of obstructive sleep ap- nea syndrome Tongue muscles, soft palate and uvula relax and/or sag (Fig. 2), causing snoring, difficulty breathing and breathing cessa- tion. Obesity, alcohol consump- tion and sleep medications can exacerbate the condition. Snor- ing and gasping for air causes the person to wake several times a night, preventing the person from getting the proper sleep needed to function. Sleep apnea is often present in people who are overweight, have physical abnormalities such as a deviated septum or have other abnormalities of the nose or throat. The sleeper tries to breathe, creating a tighter seal, which decreases oxygen flow to the brain. The sleeper awakens gasping for air. Effects and oral effects Studies on sleep apnea are fairly new, and diagnostic evidence is evolving. Snoring is one of the symptoms of obstructive sleep apnea syndrome; however, not all individuals who snore neces- sarily have OSAS. Friedlander says, “Even when the airway is partially open, obstruction oc- curs frequently and results in a loud irregular snoring sound caused by air rushing through the narrow passage and stimu- lating the soft palate, uvula, throat walls and tongue to vi- brate.”5 If an OSAS patient is left untreated, the condition can worsen over time. Risk can in- crease for hypertension, stroke, myocardial infarction, anoxic seizures and sudden death while asleep.3 Sleep apnea can be al- leviated with oral devices and/ or surgical procedures, how- ever some complications have arisen in the oral cavity because of some of the devices used to correct or minimize obstruc-tive sleep apnea. Signs and symptoms Dental professionals may be the first health-care providers to suspect possible OSAS in a patient5 because of signs and symptoms exhibited within the oral cavity. These include: “mac- roglossia (Fig. 3) and enlarged pharynx, narrowed posterior airway space resulting from a long soft palate by the uvula ly- ing below the base of the tongue; the tongue lying above the man- dibular plane of occlusion and small mandible.”5 Signs and symptoms of OSAS while sleeping can include drooling, xerostomia, restless- ness, bruxism, choking or gasp- ing, snoring, breathing pauses and diaphoresis. But an individ- ual’s symptoms associated with OSAS are not limited to sleeping problems. During waking hours the patient may experience de- pression, difficulty concentrat- ing, fatigue and insomnia. Other signs can include gastroesopha- geal reflux disease (GERD), irri- tability and sleepiness through- out the day. Coughlin says, “If OSAS continues to be untreated or it is never diagnosed, the sleeping disorder may elevate blood pressure and the potential for mortality increases.”6 What to look for Maglioca says, “The population with OSAS is a heterogeneous group, and have a wide range of physical attributes. Not all patients with OSAS have all of these physical features.”7 The most common orofacial charac- teristics encountered include a retrognathic mandible, narrow palate, large neck circumfer- ence, long soft palate (which leads to dentists being unable to visualize the entire length of the uvula when the patient’s mouth is open wide), tonsillar hypertro- phy, deviated nasal septum and relative macroglossia. Potential outcomes of non- treatment Patients with OSAS have inter- rupted sleep patterns because the obstruction of airflow causes prolonged interruptions in their breathing while they sleep (up to 40 seconds). Because the con- dition can lead to a reduction of oxygen in the blood stream, a host of medical complications can occur. Individuals with ob- structive sleep apnea can ex- perience worsening snor-ing, which is caused by vibration of the partially collapsed soft palate as air passes. Respiratory events, which deplete certain stages of non-REM and REM sleep, contribute to sleep fragmenta- tion and unrefreshing sleep.7 Because of the lack of sleep, an OSAS sufferer may have diffi- culty 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, nar- rowing the air passage. Treatments Oral devices and surgical inter- vention are the procedures used to treat OSAS. An oral appliance (Fig. 4) is a small acrylic device that fits over the upper and low- er teeth or tongue (similar to an orthodontic retainer or mouth guard). This device slightly ad- vances the lower jaw or tongue, which moves the base of the tongue forward and opens the airway. This improves breath- ing and reduces snoring and ap- nea. The appliance is fabricated and customized for each patient by a dentist experienced in the treatment of snoring and sleep apnea. The appliances are com- fortable and 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 de- vices, 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 fabrica- tion. The devices fit comforta- bly over the upper and lower teeth, positioning the lower jaw slightly forward, advanc- ing the tongue and soft tissues of the throat to open the airway. Some of the “repositioners are designed to hold the mandible Fig. 1. The position of the tongue and mandible with nor- mal and open airway while sleeping. (Photos/Provided by Sleep Group Solutions) Fig. 2. The position of the tongue and mandible showing blocked airway that occurs with obstructive sleep apnea. Fig. 3. Macroglossia (enlarged tongue). Fig. 4. One of many oral devices used to relieve sleep ap- nea. 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) > Page 9