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Transcript of No Slide Title · Vertical open bite Reduced interarch contacts Posterior cross bite No Change 70...
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Point: Non-surgical Management
of Obstructive Sleep Apnea
by
Alan A. Lowe DMD, PhD, FRCD(C)
AAO 115th Annual Session May 18, 2015
UBC Dentistry Sleep Apnea Team
Alan A. Lowe Professor
Fernanda Almeida Assistant Professor
Ben Pliska Assistant Professor
Hui Chen Clinical Assistant Professor
Bing-shuang Zou Visiting Clinical Associate Professor
Kentaro Okuno Visiting Clinical Lecturer
Mary Wong Programmer/Data Base Manager
Sandra Harrison Clinical Coordinator
Sundus Hussain Clinical Trials Manager
Sleep Disordered Breathing
Snoring Upper Airway Obstructive
Resistance Sleep Apnea
Syndrome
Mild Mild Mild
Moderate Moderate Moderate
Severe Severe Severe
+/- Symptoms ++/- Symptoms ++++/- Symptoms
+/-Health Implications ++/-Health Implications +++++Health Implications
Definitions Apnea
Cessation of airflow > 10 sec whereby the drop in airflow amplitude is > 90% of the baseline
Hypopnea
Breathing that is shallower or slower than normal by
> 30% for at least 10 seconds
Desaturation
A drop of >4% SpO2. A value below 90% is considered abnormal
Severity is classified by the Apnea Hypopnea Index (AHI)
0-5 events/hr Normal
5-15 Mild
15-30 Moderate
>30 Severe
Management of
Sleep Disordered Breathing
1) Avoidance of Risk Factors
2) Nasal Continuous Positive Airway Pressure (nCPAP)
3) Oral Appliances – More than 130 options
4) Surgery
AADSM Treatment Protocol June 2013
Physician medical assessment must be made before OA therapy
Diagnostic sleep study is interpreted by a medical sleep specialist
After initial calibration of a custom-made OA, dentist may obtain
objective data to verify improvement
After final calibration, dentist refers OA patient back to physician for
medical evaluation and assessment of OA outcomes
Patients diagnosed with primary snoring may be treated without
objective follow-up data
Knowledge of various appliances is recommended
Dentists have responsibility to routinely pursue additional education in
the field and to comply with applicable regulations
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AADSM/AASM Guidelines Feb 2015
RECOMMENDTIONS
42a When a sleep physician prescribes an OA for adult OSA,
qualified dentist to use a custom titratable OA (G)
42b Sleep physicians to prescribe OAs for adult OSAs who are
intolerant of CPAP or prefer an alternate therapy (S)
42c Qualified dentists oversee dental-related side effects or
occlusal changes to reduce their incidence (G)
42d Sleep physicians conduct follow-up OA sleep test for
adult OSAs to confirm efficacy (G)
42e Both sleep physicians and qualified dentists request adult
OSA OA patients to return for periodic office visits (G)
OA Modes of Action OA Modes of Action
Mandibular Repositioners Preformed “Boil and Bite”
Laboratory Manufactured
Single jaw position vs titratable
Tongue Retainers
Preformed
Laboratory Manufactured
Mandibular Repositioner Herbst
SnoreGuard Narval
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SomnoDent TAP
Klearway Tongue Retaining Device
Titration Aids
Patient or bed partner titration goals
Oximetry at home
Portable monitoring at home
Polysomnogram attended in the laboratory
OA Patient Titration Goals
• The patient feels more rested during the day and experiences deep
uninterrupted sleep.
• A resolution of morning headaches has occurred.
• An inability to tolerate any further advancement.
• A change in dream patterns may indicate REM catch up.
• A history from the bed partner (bed side tape recorder) that the
snoring intensity and/or frequency has changed. Usually a Snore
Score of 2 or 3 suggests that the airway is open. However, be
cautious of silent apneics until after the follow up analysis is
completed.
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Why are Oral Appliances
Effective?
Airway Size
Tongue and Jaw Muscle Activity
Mandibular Posture and Bruxism
Before Insertion After Insertion
Before Insertion After Insertion Before Insertion After Insertion
VERTICAL MANDIBULAR POSTURE BEFORE
DURING AND AFTER APNEIC EVENTS
During NREM
Opening was larger in latter half of apneic event than
before and at onset
Opening progressively increased during apneic event
Opening decreased at end of apneic event
During REM
No significant change
Oral appliances may be effective since they stabilize
mandibular posture during apneic events
TIME IN EACH RANGE DURING NREM AND REM
FOR OSA PATIENTS AND CONTROLS
During NREM
Open 2 to 2.5 less in OSA
Open 5 to 10 and more greater in OSA
During REM
Open 0 to 2.5 less in OSA
% total time open more than 5 is larger in OSA
patients (69.3) than in controls (11.1) during
NREM sleep
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Criteria Mild Moderate
Subjective 36% 20%
Clinical 82% 50%
RJM 54% 40%
Bruxism (2 of 3) 55% 40%
Overall 48%
Control 8%
L24
OA and Sleep Bruxism
An adjustable OA reduced episodes + number of bursts/hr and SB episodes with tooth-grinding noises
25% protrusion reduced SB events by 39%
75% protrusion reduced SB events by 47%
An OA may be an alternative for SB and snoring/OSA patients
Landy-Schonbeck et al, Int J Prosthodont 2009; 22:251-259
Snoring and Occlusal Splints
Maxillary occlusal splint worn for 7 nights in subjects with snoring and OSA
AHI increased 50% in half of the patients
Snoring time increased by 40%
Significant risk of aggravation of respiratory disturbances
Potential reduction of intraoral and tongue space as well as an increase in the vertical dimension
Gagnon et al, Int J Posthodont 2004;17:447-53
MINIMUM SaO2
70
75
80
85
90
95
CPAP OA
Baseline
Outcome
*p<0.001 *p<0.01
APNEA + HYPOPNEA INDEX
0
10
20
30
40
50
CPAP OA
Baseline
Outcome
*p<0.001 *p<0.001
EPWORTH SLEEPINESS SCALE
0
2
4
6
8
10
12
14
16
CPAP OA
Baseline
Outcome
*p<0.001 *p<0.002
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QUALITY OF LIFE
0
1
2
3
4
5
6
7
CPAP OA
Baseline Outcome
*p<0.001 *p<0.001 SAQLI
Total
Score
Systolic (SBP) & Diastolic (DBP)
20
40
60
80
100
120
140
160
180
16
:00
17
:00
18
:00
19
:00
20
:00
21
:00
22
:00
23
:00
0:0
0
1:0
0
2:0
0
3:0
0
4:0
0
5:0
0
6:0
0
7:0
0
8:0
0
9:0
0
10
:00
11
:00
12
:00
mm
Hg
◆: Pre-SBP. ◆ :Post-SBP, ▲: Pre-DBP, ▲ :Post-DBP
Carotid Artery Calcification (CAC) Shapes Carotid Artery Calcification (CAC) Shapes
Ovoid Linear Irregular Japanese 66Y F
BMI: 27.4
AHI: 20
Shape: ovoid
Visualization: fair
Case 1 Ovoid
Case 1 Ovoid
Case 2 Linear +
Osteophyte
Japanese 53Y M
BMI: 24.7
AHI: 25.1
Shape: linear
Visualization: good
epiglottis
thyroid cartilage
osteophyte
Japanese Data Canadian Data
Total Calcification NO
calcification Total Calcification
NO
calcification
N 1012 96 916 508 34 474
Sex (M/F) 821/191 72/24 749/167 392/116 26/8 366/108
Age 50.5±14.5 57.6±12.6** 49.8±14.5** 48.5±11.2 50.8±12.9 48.33±11.1
BMI 26.0±4.7 25.4±3.7 26.0±4.7 29.5±5.5 26.9±3.2* 29.7±5.6*
AHI 27.4±23.6 28.6±21.6 27.3±23.8 29.8±21.6 25.0±18.8 30.1±21.7
* Statistical significance (p<0.01) ** Statistical significance (p<0.000)
Prevalence of
calcification
6.7%
Prevalence of
calcification
9.5%
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CAC Follow Up CAC Follow Up
After identifying a possible CAC on a lateral headfilm or on a panorex, it would be appropriate to refer the patient to a radiologist experienced in the field to confirm the finding.
Further tests coordinated by the patient’s physician may include a CT scan and/or a color Doppler ultrasound image.
Sample of a Carotid Artery Doppler Image Sample of a Carotid Artery Doppler Image
Occlusal Changes After Five Years of OA Use
Favorable Change
Correction of Class ll molar
Correction of Class ll cuspid
Reduced OJ or OB
Reduced palatal impingement
Reduced lower incisor crowding
Unfavorable Change
Edge to edge incisors
Reverse OJ or OB
Vertical open bite
Reduced interarch contacts
Posterior cross bite
No Change 70 OSA
Patients
Favorable
29 (41.4%)
Unfavorable
31 (44.3%)
Small
13
Intermediate
13
Large
3
Large
8
Intermediate
15
Small
8
Change
60 (85.7%)
No Change
10 (14.3%)
Skeletal Type and Outcomes
Class I Class II/1 Class II/2 Class III
No Change 12.5% 10% 20% 50%
Favorable 25.0% 90% 80% -
Unfavorable 62.5% - - 50%
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Four Years of Profile Lite Nasal Mask
(Respironics)
SNA SNB
SNPg Convexity ANB
SNU1
Tsuda, H., Almeida, F.R., Tsuda, T., Moritsuchi, Y. and Lowe, A.A. “Craniofacial Changes after Two Years of Nasal
Continuous Positive Airway Pressure Use in Patients with Obstructive Sleep Apnea”, Chest, 138:870-874, (2010).
Superimposition on the SN line of a typical OSA subject
at baseline and after 35M of nCPCP wear
____ baseline
……. follow-up
Breeze SleepGear –
Puritan Bennett
Mirage Swift -
ResMed
NASAL PILLOW ALTERNATIVES
Profile Lite Nasal
Mask- Respironics
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Date Questionnaire Min O2 (%) RDI/hr AHI/hr ODI/hr
Pretreatment 2008/2/29 69 89 8 5 2.5
Posttreatment (with Klearway) 2008/9/20 34 94 2.4 0 0
Posttreatment (without Klearway) 2008/9/30 93 3.2 2.6 1
Portable Monitor (Watch-Pat)
Some OSA Guidelines for Orthodontists
Don’t hesitate to refer to adult/pediatric sleep specialists
Avoid treatment without a written referral from a physician
Be cautious in patients with previous orthodontic therapy
Use recognized appliances with RCT research
Both case and appliance selection are very important
Be aware of silent apneics and post titration follow up
Don’t over treat post OA or nCPAP occlusal changes
Not all Class IIs have OSA / not all OSAs are Class II
Be engaged in this rapidly changing and exciting field
American Academy of Dental
Sleep Medicine
2510 N Frontage Road,
Darien, Illinois 60561
Phone: (630) 737-9705 Fax: (630) 737-9790
Web Site: www.aadsm.org
The Web site has information about the AADSM, a geographic
listing of members, certification status and Web site links.
Alan A. Lowe, DMD, PhD, FRCD(C)
Professor and Chair, Division of Orthodontics
Director, Frontier Clinical Research Center
Department of Oral Health Sciences
Faculty of Dentistry, The University of British Columbia
2199 Wesbrook Mall, Vancouver, B.C. V6T 1Z3
Phone: (604) 822-3414 Fax: (604) 822-3562
E-mail: [email protected]
http://www.Klearway.com