This article is provided by other Clinicians to better understand about the treatment of Sleep Apnea. So I wanted to share this all of you. Please visit: www.ctsleepdentist.com

1. Snoring And Sleep Apnea
Snoring and Obstructive Sleep Apnea: in the U.S.
Oral Appliance Therapy Management
Approximately 40% of adults over 40
years old snore (about 100 million
Midwest Society of Orthodontists Americans)
October 16-17, 2009
4% of men and 2% of women have
signs and symptoms of OSA (about 12
million Americans)
Anthony J DiAngelis DMD, MPH
Chief, Department of Dentistry, HCMC
Professor, University of Minnesota
School of Dentistry OSA is as prevalent as diabetes or
asthma
Definitions Defining Severity of OSA
Apnea: Cessation of ventilation for > 10
seconds Length of time in apnea event
Hypopnea: 30-50% reduction in airflow > 10 Percentage decrease in oxygen
seconds desaturation
Apnea Index (AI): Average number of Apnea-Hypopnea Index:
apneic episodes per hour of sleep Mild OSA= 5-15 events/hour
Moderate OSA= 15-30 events/hour
Apnea-Hypopnea Index (AHI): Average Severe OSA= >30 events/hour
number of apnea plus hypopneas per hour of
sleep.
Obstructive Sleep Apnea Dangers of
Obstructive Sleep Apnea
Individuals with OSA:
5 x more heart attacks
30-45% high blood pressure
50% stroke patients have OSA
Loss of Employment
Uninsurability
Marital Discord
Increased Role of MVA’s (20%)
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2. Clinical Signs & Symptoms Predisposing Factors
Snoring: Intermittent with pauses
Excessive daytime sleepiness Age: Prevalence progressively increases
with advancing age
Awakenings / gasping or choking Obesity: Prevalence progressively
Fragmented, non refreshing
Fragmented non-refreshing, light increases with increasing weight
sleep Gender: 5 to 10 times more common in
Poor memory, clouded intellect males
Irritability, personality changes Disproportionate upper airway anatomy
ET0H, sedative-hypnotic drugs in late PM
Decreased sex drive, impotence
Hypothyroidism
Morning headaches
Diagnosis Management of Snoring and OSA
Non-Surgical
Avoidance of risk factors
Pharmacologic agents – not very effective
Positive airway pressure (continuous or bilevel)
Oral appliance therapy
Surgical
Tracheostomy
Uvulopalatopharyngoplasty – UPPP
LAUP
Pillar Procedure
Hyoid Suspension/Genioglossus Advancement
Max. / Mand. Advancement
How Do They Work?
Oral appliances are worn in the
mouth during sleep to prevent
Oral Appliance Therapy the oropharyngeal tissues and
p y g
the base of tongue from
collapsing and obstructing the
upper airway.
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3. Advancement = Increased Airway
Oral Appliances May Function
in 3 Basic Ways
Repositioning the Mandible, Tongue,
Soft Palate and Hyoid Bone
Stabilizing the Mandible / Tongue /
Hyoid Bone
Increasing Baseline Genioglossus
Muscle Activity
Case Types Contraindications
Primary Snoring
Mild / Moderate OSA Central Sleep Apnea
CPAP Intolerant – any level Significant TMJ Disorder (
g (MRD’S)
)
Surgical Failures Inadequate Dental Status (MRD’S)
Adjunctive Therapy
Unmotivated Patient
Occasional, Short-term Substitutive
Therapy
Functional Classification of
Oral Appliances
Categorized by Mode of Action:
Mandibular Repositioners
p
Tongue Retainers
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4. Design Variations Tongue Retaining Device
(TRD)
Method of Retention
Flexibility of Material
Adjustability
j y
Vertical Opening
Freedom of Jaw Movement
Lab vs. Office Construction
PM Positioner TAP 3
TAP 3 Somnodent
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5. Klearway
Evaluation and Consultation
MD Referral
Review Sleep Study
Review History
Oral E
O l Examination
i ti
Informed Consent
Models and George Gauge Bite
MRD Type
Letters to MD and Patient’s DDS
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6. Side Effects and Complications
Final GG bite registration
Common Side Effects:
Starting mandibular
treatment position is ▪ Excessive Salivation
60% of maximum ▪ Transient Discomfort – Teeth, TMJ
protrusion ▪ Dry Mouth
Minimum of 7mm ▪ S f Tissue Irritation
Soft Ti I i i
protrusion needed
3-5 mm interincisal ▪ Temporary, Minor Disharmonies
opening in anterior Complications:
Mandible positioned ▪ Significant TMJ Discomfort/Dysfunction
symmetrically ▪ Permanent Occlusal Changes
forward
MRD Success Rates
Diagnosis % Success
• snoring 90+
• mild OSA 80+
• moderate OSA 70+
• Severe OSA 50-50
Follow-up Evaluation During
Periodic Follow Up Appliance Therapy
Medical Assessment
Dental Assessment History:
▪ Snoring
▪ Apneic Events
▪ Quality of Sleep
▪ Daytime fatigue (EDS)
▪ Focus
▪ Side Effects
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7. Follow-up Evaluation During Follow-up Schedule During
Appliance Therapy Appliance Therapy
Examination: First Year:
▪ Appliance Fit and Comfort ▪ 3 weeks post insertion
▪ OB OJ
OB, ▪ 3 month intervals
▪ Occlusal Contact Second Year:
▪ Muscle Tenderness ▪ 6 months
▪ TMJ Assessment Annual Thereafter
Post MAD
Recommend Follow-up Pre MAD
54 y.o. Female 56 y.o Female
Evaluation with Physician
and PSG with Oral Appliance
For patients with moderate to severe OSA:
Refer for s eep study when pat e t has
e e o sleep e patient as
relief of symptoms
During study, mandibular position is
advanced 1 mm/1/2 hour, if needed, until
estimated AHI is below 10 events/hour
Long-Term Sequellae of Oral Appliance Therapy
in Obstructive Sleep Apnea
Almeida F R et al. Am J Orthod Conclusions
Dentofac Orthop 129:195-213, 2006
Skeletal Types and Outcomes
Long-term oral appliance therapy affects the
Class I Class II/l Class II/2 Class III
entire occlusion in all three dimensions:
No Change 12.5% 10% 20% 50%
Favorable
Fa orable 25% 90% 80% ---
Transversely: Arch widths increase;
y ;
overjets decrease.
Unfavorable 62.5% --- --- 50%
Antero-posteriorly: Mandibular
Other Findings dentition moves forward; anterior overjets
Overjet: Decreased anterior to mesial of the first molars decrease
Overbite: Significantly decreased in the entire arch
Arch Width: Mandibular arch increased more than the maxillary Vertically: Overbites decrease
Curve of Spee: Flattened significantly in the premolar area after
long-term therapy.
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8. Tooth movement is much more
common in patients who have had Risks vs. Benefits
orthodontic therapy
Our responsibility lies in
Tooth movement is guaranteed in adequately treating a medical
patients who have had adult condition with a d t l d i
diti ith dental device
orthodontics . while recognizing and managing
(as best we can) occlusal changes
Alan Lowe BDS, PhD
and to a lesser degree TMJ
symptamotology.
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