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Dental Tribune Middle East & Africa Edition July-August 2015

Dental Tribune Middle East & Africa Edition | July-August 2015 9mCME < Page 8 anteriorinferiorly, constructed to position the mandible at 75 per- cent of the maximal mandibu- lar advancement and within a 7 mm opening between upper and lower incisors”8 with no adverse effects to the temporal mandibular joint. The MADs have an adjustment mechanism built into the de- vice, enabling users to gradually change the position of the bot- tom jaw under dental supervi- sion to improve the effectiveness of the device. Oral appliances used for OSAS patients cause a “mandibular advancement, including de- velopment of posterior open bite, altered inclination of in- cisors and decreased anterior open bite.”8 Through the use of various imaging techniques, re- search on appliances used for OSAS has identified various den- tal/skeletal changes that occur. One of the most common effects, referenced in many studies, is the degree of vertical and hori- zontal overlap of the teeth (over- jet and overbite, respectively).9 The adjustment mechanism makes it possible to position the device to best address a patient’s particular needs. The tongue-retaining device is custom-made using a softer, pli- able material with a compart- ment that fits around the tongue to hold it forward by means of suction. This device is used most for patients with dentures or patients who cannot adequately advance their lower jaw. Such patients must be able to breathe well through their nose, or they may have difficulty tolerating this appliance. There are other recommended treatments, some involving be- havioral therapy, that patients may be less likely to comply with, such as “non-supine sleep, [avoiding] late evening [food] consumption, weight loss, ab- staining from drinking alcoholic beverages and a lifetime of re- quired nightly use of continu- ous compressed air delivered by a CPAP (continuous positive air-way pressure) machine via a nasal mask”3 (Fig. 5). The CPAP machines work when there is a compliant patient. If the patient is not compliant, there are other oral-appliance therapies that may be used, but CPAP remains the “gold stand- ard’ treatment for sleep apnea [and] the objective success rate of any other treatment must be judged against it.”10 If a patient chooses oral devices over a CPAP machine, the dental team may be responsible for the fabri- cation of the oral devices. Surgical treatments Surgery is usually done in se- vere cases of OSAS or as an al- ternate or last-resort procedure. The main surgical treatments offered for OSAS often target the anatomical areas of the pos- terior airway where collapse is suspected to occur. Treatment is designed to enlarge the pos- terior airway space, reduce air- way collapsibility and, ideally, stabilize the airway for the long term. Surgery has the advantage of correcting any craniofacial abnormalities that may be the cause of the OSAS and of re- moving the variable of patient compliance that is required with other long-term treatment strat- egies. Obstructive sleep apnea syn- drome sometimes occurs in patients with a retrognathic po- sitioning of the mandible (Fig. 6). People who have a receding chin related to a small lower jaw are more likely to snore because there is less room in the back of the throat for the soft tissues and tongue. This reduction in space decreases the size of the air pas- sage and causes increased snor- ing. Some patients undergo “max- illa-mandibular advancement surgery.”3 Oral and maxillofacial surgeons engaging in correc- tive surgery communicate with the general dentist, because whenever an OSAS patient un- dergoes surgery, treatment plans need to be suspended in anticipationofchangestothepa- tient’s occlusion. Hoffstein says, “Maxilla-mandibular advance- ment (MMA) surgery, which is based on traditional orthognath- ic surgery techniques, has been proven effective for a range of OSAS disease.”10 Surgery allows the repositioning of the tongue. Additionally, de Almeida says, “These bone movements pull the base of the tongue forward and upward, thereby enlarging the posterior airway space, cre- ating more anterior space for the tongue. The bony segments are fixed rigidly with screws and plates to assist in healing and to resist the pull of soft tissue that may cause skeletal relapse.4 Dental team’s role in identify- ing sleep apnea Obstructive sleep apnea re- quires appropriate diagnosis and treatment. Interdisciplinary communication is paramount when cases are handled by a team methodology. The dentist should work closely with other health-care professionals. Re- ferral of patients to a physician indicates the dentist’s desire to make certain that the patient receives the best care possible. Dental professionals are crucial advocates involved in the man- agement of OSAS and should be aware of the complications that can be caused by the disorder. Asking questions about pa- tients’ sleep habits can stimu- late awareness for the general dentists and hygienist, enabling them to refer a patient to a phy- sician who specializes in sleep disorders. Use of a standardized questionnaire similar to a medi- cal history will ensure that every patient is screened for OSAS (see example in appendix). Identify- ing the underlying causes of OSAS and recommending an appropriate course of treatment can help patients maintain qual- ity of life and reduce morbidity rates. Prinsell says, “This should be a working relationship be- tween the medical community.”3 Teamwork between dental and medical professions Patients with OSAS have a high- er risk for hypertension, which can lead to other physical com- plications. Dental professionals working with physicians should be familiar with the medications andappliancesusedforsleepap- nea and the oral complications that can result from the different treatments. Treatment for sleep apnea and snoring can help pa- tients get the rest they need to reduce the medical complica- tions and improve their function during the day. The dental team will be involved in monitoring any occlusal changes that result from mouth devices used in the sleep-disorder therapy. When working with patients who have been prescribed an oral appliance, the dental hy- gienist needs to recommend mandatory dental visits as part of the treatment plan to keep a record of changes that might occur in the occlusal bite or to stay ahead of other dental prob- lems that can occur because of use of the appliance. Magliocca and Helman say, “In addition to the patient’s medical history, the dentist’s clinical examination findings influence treatment planning.” It is also important to be aware that patients may be taking med- ication that creates xerostomic effects.7 Kalan and Kenyon say, “There are, also, certain types of CPAP delivery that may add to the patient’s complaints of xerostomia.”11 Medications may sometimes be used to treat de- pression experienced by some patients with OSAS. These medications may contribute to causing the oral cavity to be dry. Patients also might begin to neglect daily oral hygiene. Dentists and hygienists should recommend and prescribe arti- ficial saliva products and regular fluoride applications for patients with xerostomia who are using the CPAP devices. While the in- cidence of caries has not been reviewed in the OSAS popula- tion, it would seem especially prudent to educate patients with xerostomia about avoiding cari- ogenic foods and beverages.7 Dental professionals need to be aware of the impact certain sur- gery procedures within the oral cavity can have on patients who are using a CPAP machine. For example, Kapur says, “Reflect- ing a mucoperiosteal flap to ac- complish surgical extractions or other procedures may preclude the patient from using CPAP for one to two evenings to avoid the possible risk of developing sub- cutaneous emphysema.”12 Because occlusal changes can occur with OSAS therapy, com- munication between the patient, dentist, hygienist and the phy- sician who prescribed the oral appliance is essential. Some pa- tients may not notice or may not be affected by changes in their occlusion while using an oral appliance, but problems may still exist. Robertson et al. sug- gest “keeping the patient’s bite opening to a minimum when fabricating an appliance to re- duce the impact on the occlu- sion.”13 When restorative work is be done on OSAS patients, such as crowns or fillings, adjust- ments to the existing appliance — or fitting of a new appliance — may be needed. The process of adjusting or creating a new appliance needs to be done with the oral surgeon or physician who prescribed the oral device. The prevalence of OSAS may be higher than estimated, and medical and dental health-care professionals can “offer these mCME SELF INSTRUCTION PROGRAM CAPPmea together with Dental Tribune provides the opportunity with its mCME - Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspective and subject matter. Membership: Yearly membership subscription for mCME: 900 AED One Time article newspaper subscription: 250 AED per issue. After the payment, you will receive your membership number and Allowing you to start the program. Completion of mCME • mCME participants are required to read the continuing medical education (CME) articles published in each issue. • Each article offers 2 CME Credit and are followed by a quiz Questionnaire online, which is available on http://www. cappmea.com/mCME/questionnaires.html. • Each quiz has to be returned to events@cappmea.com or faxed to: +97143686883 in three months from the publication date. • A minimum passing score of 80% must be achieved in order to claim credit. • No more than two answered questions can be submitted at the same time • Validity of the article – 3 months • Validity of the subscription – 1 year • Collection of Credit hours: You will receive the summary report with Certificate, maximum one month after the expiry date of your membership. For single subscription certificates and summary reports will be sent one month after the publication of the article. The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact events@cappmea.com or +971 4 3616174 FOR INTERACTION WITH THE AUTHORS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. Fig. 5. CPAP machine nosepiece. Adjustments need to be made to the CPAP nosepiece and mouthpiece. Mouthpiece can cause pressure and create lesions in the upper anterior gingival tissues. Fig. 6. Retrognathic or receding jaw. (Photo/Provided by Oral Facial Reconstruction and Implant Center of Florida, www.oralfacial.com/ doctors-luis-cardenas.php) > Page 10 patients the full range of avail- able treatment options to defeat this often fatal illness.”6 Adding sleep-related questions to the written or oral medical history and consideration of both oro- facial and physical findings may result in the detection of a sleep disorder.8,14,15 Dental hygienists can ask questions, such as: “How many pillows do you sleep with? Does your spouse complain that you snore? Are you grinding or clenching? Do you wake up with headaches in the morning? Do you wake up with a dry mouth?” The routine oral assessment that hygienists provide can aide in recognizing conditions per- taining to OSAS. Hygienists can facilitate the management of the patient with sleep apnea by recommending oral care prod- ucts to reduce xerostomia and to reduce inflammation of gingiva for sleep apnea patients who snore. Dental health-care pro- fessionals should refer patients to physicians who manage OSAS patients on a regular basis. Dental hygienists see patients frequently and often on a routine bases, so they are often the first to observe variations in the oral cavity. Cooperation between hy- gienists and dentists and medi- cal health-care professionals who treat patients with OSAS creates an advantage to the pa- tient for overall health care. Treatment plans for patients with sleep apnea and sleep dis- orders, along with the associated medications being used by such patients, should be included in the medical history in the pa- tient’s charts. This will ensure the dental team is aware of any changes in the oral cavity and is +97143616174

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