Part II: Introduction to Sleep-Disordered Breathing

Gregory K. Essick, DDS, PhD; Jonathan A. Parker, DDS; Jamison R. Spencer, DMD, MS; Andrew R. Blank, AAS, BS

July 2016RN - Expires December 31st, 2019

Inside Dental Technology

Abstract

This introduction to sleep-disordered breathing (SDB) provides a concise yet comprehensive overview of the management of and screening for snoring and obstructive sleep apnea (OSA). Successful management of SBD often includes positive-airway pressure therapy, oral appliance therapy, or soft- or hard-tissue surgeries of the structures surrounding the airway. Given the high prevalence of SDB in today’s society, the entire dental team can provide a valuable service in screening and in treating patients who are candidates for oral appliance therapy.

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Sleep problems in our society are very prevalent. National Sleep Foundation surveys show that 75% of Americans report at least one sleep symptom and approximately 60% of adults drive while drowsy each year.1 Sixty-seven percent of adults snore. This condition affects the quality of their sleep and the sleep of others near them. Obstructive sleep apnea (OSA) is one of the most prevalent sleep disorders and is affecting 26% of adults between the ages of 30 and 70.2 People with untreated OSA can experience a significantly reduced quality of life. It can lead to difficulty in daytime functioning due to daytime sleepiness, fatigue, irritability, and decreased cognitive function. In addition, research studies show that people with OSA have a higher risk of cardiovascular disease (hypertension, heart attack, stroke, atrial fibrillation, etc.), diabetes, asthma, cancer, and dementia.3,4 People with this condition are also more likely to have motor vehicle accidents, which affects everyone.5,6

Part I of this series addressed the physiology, diagnosis, and medical and dental consequences of OSA, and can be accessed at insidedentaltech.com/idt849. This article will cover the management of OSA, as well as the current state of screening for OSA in the dental practice.

Management Strategies

CPAP

Continuous Positive Airway Pressure (CPAP) is the gold-standard treatment for OSA.23,37 Using a mask worn on the face, air is forced into the nose and/or mouth to keep the airway from collapsing during sleep. The pressure required to maintain a patent upper airway is traditionally determined by a second sleep study or the second half of the diagnostic study (see Part I). During this CPAP titration, the technologist systematically increases the air pressure while respiration data are being inspected (Figure 1). The aim is to determine the minimum pressure that keeps the airway open during those conditions in which the airway is most likely to collapse, specifically REM sleep and supine sleep (sleeping on one’s back). Because of the expense of a second sleep study, some third-party payers prefer that the patient be prescribed a CPAP machine that automatically determines the pressure (auto-CPAP), thus forgoing CPAP titration in a sleep laboratory.

CPAP reduces the apnea-hypopnea index (AHI) to <10 events>38,39 However, only about 50% of patients are able to tolerate its use long-term, and it is also very common for patients to use their CPAP for only 4-6 hours per night.40,41 Patient complaints include: presence and contact by headgear and chin straps, claustrophobia, unstable or inadequate fit of mask to facial contours, air leakage, mask-related skin ulceration and headache, aerophagia (swallowing air), and uncomfortably high pressure levels (Figure 2).42,43 Durable medical equipment (DME) providers work with patients to find a comfortable mask and level of humidification to improve tolerance. Some patients find modified forms of CPAP more tolerable, eg, Auto-CPAP in which an onboard computer determines the appropriate pressure from moment to moment, or Bi-level-CPAP, in which a higher pressure is delivered during inspiration and a lower pressure during expiration. Cognitive behavioral training has been used in an attempt to desensitize patients to the use of CPAP and thus improve adherence to therapy.

Based on studies of patients’ use of CPAP and its impact on daytime sleepiness and quality of life, compliance to therapy has been defined as use for a minimum of four hours per night on at least five nights per week.42 This definition is often used, as well, for other therapies for OSA. Most CPAP machines today have monitoring chips that record nightly use, pressure delivered, and measures of sleep respiration pertaining to the efficacy of therapy. This information can either be downloaded by the DME company or clinician, or with some new systems automatically transmitted via cell phone or Internet directly to the DME company or treating physician, who is able to make adjustments to the machine’s settings remotely.

Oral Appliances

Oral appliances represent an alternative to CPAP.44 Most commonly used is a mandibular advancement device (MAD), also known as a mandibular advancement splint (MAS) or mandibular repositioning appliance (MRA) (Figure 3). The custom-fabricated, adjustable MAD is recognized as the standard-of-care oral appliance by the American Academy of Dental Sleep Medicine, and is the appliance of most relevance to the dental technologist.45 It will be described in detail in Parts III and IV of this series.

In addition to MADs, other oral appliances used to treat SDB include tongue devices.46,47,48 These devices include stock/prefabricated (Figure 4) or custom-fabricated (Figure 5) suction cups to hold the tongue forward or a dental appliance that pushes the base of the tongue forward using an acrylic appendage from the posterior aspect of the appliance (Figure 6). These tongue devices are used less frequently than MADs but may be indicated for edentulous patients, patients undergoing orthodontic treatment, or patients who cannot protrude the jaw (as is the case of patients who have undergone joint replacement surgery).

The MAD improves airway patency by stabilizing the jaw in a forward and (typically) closed mouth position.45 Because the tongue, its base, and the soft palate have attachments to the jaw, these tissues move forward, increasing the upper airway space. Also, the jaw is prevented from sliding or rotating backward during supine sleep. Both actions, if not prevented, can lead to upper airway collapse. Because airflow behind the soft palate becomes less turbulent and/or the soft palate becomes tauter, snoring is reduced or eliminated. Some studies have argued that neuromuscular reflexes that protect the airway work more effectively when a patient with OSA uses a MAD.49

Based on literature prior to 2005, MADs were found to reduce the AHI to <10 events>44 Multiple studies over the past decade, however, have shown that when properly adjusted, MADs are not inferior to CPAP in efficacy for patients with mild or moderate disease and that a higher percentage of patients with severe OSA — as high as 60% — can be adequately treated.38,39 The literature also confirms that any shortfall in efficacy compared to CPAP is compensated by the substantially better compliance to therapy.50,51 Reports over the past 15 years suggest that approximately 75% of patients are still using their appliance 2-3 years after delivery.52,53

Recently, compliance monitors, simpler than those used in CPAP machines, have been introduced for MADs (Figure 7).51,54,55 They are fabricated into the oral appliance by the dental laboratory technologist (Figure 8). Based on early studies with these types of monitoring devices, approximately 80% of patients were found to be compliant at one year post-delivery of appliance.51 Patients’ reports of utilization match the data recorded by these chips remarkably well. With greater utilization of therapy even with lower efficacy, MADs provide similar treatment effectiveness to that of CPAP and are predicted to have similar long-term outcomes on health. The limited studies conducted to date show that MADs and CPAP are equally effective in improving cardiovascular outcomes in patients with OSA.56,57

Combination Therapy

Approximately 25% of patients will not respond adequately to MAD therapy.38,39,58 If these patients have failed CPAP therapy, combination therapy provides the next logical step in the patients’ treatment (Figure 9 ).59 When used in combination with CPAP, a MAD serves as an adjunct to improve its tolerance by lowering the pressure required to keep the airway open.60 With lower pressures, there are fewer pressure-related complaints that often lead patients to abandon therapy. These include air leakage and need to over-tighten the mask, arousals from sleep due to the air stimulation, and air entering the stomach (aerophagia). MADs also stabilize the jaw in a forward and upward position, thereby improving the fit and stability of masks that cover both the nose and mouth or eliminating the need for a full-face mask. Because the oral appliance lowers the upper airway resistance, the efficacy of CPAP can be improved. The use of a MAD to improve the tolerance and efficacy of CPAP remains largely “off-label,” although some third-party payers will cover both therapies at the same time. Research funding has not been available to conduct randomized clinical trials to study this innovative therapy, limiting its endorsement.

Other therapies that are used in combination with MADs are tongue devices and positional therapy (forced side-sleeping).61,62 In these cases, treatment with the MAD constitutes the primary therapy. The tongue device or positional therapy is considered adjunctive. The aim of these combination therapies is to reduce the frequency of respiratory events below the level achieved by use of the MAD alone.

Surgery

Many different types of surgical procedures for the soft tissues are used to increase the upper airway space. These involve using a scalpel, laser, or tissue-lesioning probe to reduce the mass of the soft palate or base of the tongue.63,64 The most common procedure historically has been uvulopalatopharyngoplasty (UPPP), or laser-assisted uvulopalatopharyngoplasty (LAUP), in which a crescent-shaped section of the soft palate is removed, including the uvula and tonsils (Figure 10 and 11). Given its poor to moderate efficacy, this procedure is used today sparingly for snoring and mild forms of SDB, but rarely for more severe forms of OSA.

In contrast to soft-tissue surgery, greater success has been reported for surgery that increases upper airway size by repositioning anteriorally the maxilla and/or mandible (Figure 12 and 13). Maxillomandibular advancement surgery for OSA involves one or more of the following: Le Fort I osteotomy, in which the maxilla is moved forward; bilateral split sagittal osteotomy, in which the body of the mandible is moved forward; and anterior inferior mental osteotomy, in which the chin is moved forward (Figure 14).65,66,67 Orthodontics is required before and after the surgery. The surgery is usually reserved for patients with severe OSA who cannot tolerate CPAP, and has been reported successful in 65-100% of patients depending on the definition of success. Unlike CPAP and oral appliances, the surgery attempts to cure, rather than manage, OSA, and compliance to therapy is 100%.

Other

Because many, if not most, patients have worse OSA when sleeping on their back than on their sides, side sleeping can be an important adjunct to other therapies for OSA or serve as an adequate monotherapy in patients who have OSA only when sleeping on their back.62 Belts and nightshirts that restrict patients’ ability to sleep on their back are commercially available.

The avoidance of substances that relax the muscles or obtund airway protective reflexes (alcohol and sedatives) is also often recommended.68 Weight loss in obese patients will decrease the severity of OSA (but will rarely cure it) and will improve the efficacy of oral appliances.69

Nasal decongestants or surgery are indicated for patients who cannot breathe through their nose while sleeping. Although not curative, measures to restore normal nasal patency can improve the effectiveness of CPAP and of oral appliances.70

Other therapies that have been introduced recently include oral suction to pull the soft palate and tongue forward, and hypoglossal nerve stimulators.71 The implanted nerve stimulator monitors sleep respiration and electrically stimulates the genioglossus muscle when breathing becomes labored, thereby increasing airway patency.

Sleep Medicine in Dentistry

Sleep Medicine in dentistry includes screening for SDB, oral appliance therapy for SDB, and orthognathic surgery and orthodontic therapies, such as Rapid Maxillary Expansion (RME), for SDB. A short discussion on screening for SDB is presented below. Parts III and IV of this series will focus on oral appliance therapy. Orthognathic surgery and orthodontics for SDB will not be considered in this series.

Screening in Dental Practice

Screening for hypertension in the dental office is standard of care. It leads to the identification of patients at risk for cardiovascular disease and their subsequent treatment. In contrast, screening for OSA — almost as prevalent in the adult population as hypertension — is rarely performed. No guidelines for the general screening of patients in a dental practice have been established and validated. Best practice dictates that patients with both clinical findings suggestive of SDB and who screen “at risk” on OSA questionnaires should be advised to see their physician or a sleep physician for an evaluation to rule out or identify sleep apnea.

Clinical findings suggestive of SDB include: being overweight, a large neck circumference/cervical fat, a small and/or retruded jaw, dental attrition (bruxism) or erosion (GERD), a long face, a narrow arch form with large or thick tongue, a long soft palate and/or uvula, large tonsils crowding the airway, presence of respiratory sounds in supine position, and falling asleep during the dental appointment (Figure 15).15,16,17 OSA questionnaires assess patients’ reports of symptoms of SDB including snoring, being told by others that their breathing stopped during sleep, daytime sleepiness or fatigue, and hypertension.72 The most common screening questionnaires were developed for administration to patients prior to surgery and thus have good to excellent sensitivity, but moderate to poor specificity.73 Thus, their use without consideration of clinical indicators of SDB classifies “at risk” a large number of patients who do not have OSA. The use of home sleep apnea testing for general screening for SDB is not endorsed by the American Academy of Sleep Medicine.19 It is particularly ill advised in the dental setting, as home sleep testing is not able to rule out sleep apnea, only in.

Patients who have OSA utilize health care resources at twice the rate of those without OSA for as far back as 10 years before they are diagnosed.74 The use of health care dollars for untreated OSA is in the billions each year. Despite the prevalence of this disorder, the impact on a person’s health and life, and the economic burden of this condition, only 15-20% of the individuals with OSA have been diagnosed.75 It is the responsibility of physicians, dentists, and other health care providers to identify people at high risk for OSA and to encourage them to have the problem evaluated, diagnosed and treated.

Disclosure

The authors had no disclosures to report.

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About the Authors

Gregory K. Essick, DDS, PhD
Professor
Department of Prosthodontics and Center for Pain Research and Innovation
School of Dentistry
University of North Carolina
Chapel Hill, NC

Jonathan A. Parker, DDS
Owner, Clinical Director
Snoring and Sleep Apnea Dental Treatment Center
Edina, MN

Jamison R. Spencer, DMD, MS
Director
The Center for Sleep Apnea and TMJ
Boise, ID

Andrew R. Blank, AAS, BS
Dental Student
East Carolina University School of Dental Medicine
Greenville, NC

Part III

The third installment of this four-part series will address oral appliances in detail, including practice guidelines, types of appliances, and side effects of therapy.

This article was double-blind peer reviewed by members of IDT’s Editorial Advisory Board

Fig 1. Impact of increasing positive airway pressure on respiratory events during sleep. Note that CPAP was administered shortly after 1 am in this split-night sleep study. The hypopneas that were observed prior to CPAP were eliminated. However, the patient exhibited RERAs until the pressure level was increased to its final value of 13 cm/H20.

Figure 1

Fig 2. Percentage of 88 CPAP-intolerant patients who expressed each of the listed complaints about CPAP (orange bars). The complaints were greatly reduced in 63 patients who subsequently received and tolerated combination therapy (gray bars). Data from Sanders et al (2015).

Figure 2

Fig 3. Six representative mandibular advancement devices. Top row, from left: TAP® appliance (tapintosleep.com), Somnodent (dorsal) appliance (somnomed.com), MicrO2™ appliance (microdental.com). Bottom row, from left: SUAD™ (Herbst) appliance (strongdental.com), Narval CC™ appliance (resmed.com) , and PM Positioner™ (adjustablepmpositioner.com). The Narval and MicrO2 appliances are computer-designed and manufactured by 3D printing and milling, respectively.

Figure 3

Fig 4. A prefabricated Tongue Stabilizing Device (Aveo TSD®). Available in sizes small, medium and large (aveotsd.com/).

Figure 4

Fig 5. A Kelgauge is used to take a registration for laboratory fabrication of a custom Tongue Retaining Device (TRD) in silicone material.

Figure 5

Fig 6. A maxillary tongue restraining device (Full Breath Solution, smlglobal.com). The posterior appendage of acrylic restrains the tongue from moving upward and backward (Figure courtesy of Space Maintainers Laboratories).

FIgure 6

Fig 7. Upper component of a TAP appliance fit with a compliance monitoring device (Figure courtesy of Airway Management, Inc).

Figure 7

Fig 8. The dental laboratory technician adds the compliance monitor, a DentiTrac® microrecorder, at the time the appliance is fabricated (Figure courtesy of Braebon Medical Corporation).

Figure 8

Fig 9. Combination therapy with CPAP and an oral appliance. The CPAP interface (nasal pillows) is secured to a post extending from the upper component of a TAP appliance to obtain its support and stability. More common than the arrangement shown here, the CPAP mask and oral appliance are not inter-connected (Figure courtesy of Dr. Martin Denbar, Austin, Texas).

Figure 9

Fig 10.  The soft palate prior to UPPP surgery and after UPPP surgery. Note that a band of scar tissue replaces the uvula and tonsils (Figures courtesy of Dr. Brent Senior, School of Medicine, University of North Carolina at Chapel Hill).

Figure 10

Fig 11. The soft palate prior to UPPP surgery and after UPPP surgery. Note that a band of scar tissue replaces the uvula and tonsils (Figures courtesy of Dr. Brent Senior, School of Medicine, University of North Carolina at Chapel Hill).

Figure 11

Fig 12. Facial profile prior to MMA surgery. The patient’s pre-surgery AHI was 132 events/hour.

Figure 12

Fig 13. Facial profile after MMA surgery. Note the more anterior position of the lips and chin relative to the nose, as compared to their positions pre-surgery. The patient’s post-surgery AHI was 16.7 events/hour.

Figure 13

Fig 14. Postsurgical panographic radiograph showing surgical osteotomies and hardware stabilizing the maxilla, mandible, and chin in their new positions.

Figure 14

Fig 15. Clinical observations raising concern about the possibility of OSA. Note the large, thick tongue with scalloping on the lateral border with highly crowded oropharynx by enlarged “kissing tonsils.”

Figure 15

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SOURCE: Inside Dental Technology | July 2016

Learning Objectives:

  • describe different management strategies for obstructive sleep apnea
  • explain the roles of dentistry in sleep medicine
  • discuss the current screening protocols for OSA and the importance of improving upon these protocols

Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.