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1. GREETINGS FROM YENEPOYA DENTAL COLLEGE
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Indian Dental Conference
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2008, Mangalore
2. OBSTRUCTIVE SLEEP
APNEA –
A Dentist’s Perspective
Dr Varghese K Paulose
Department of Orthodontics
Yenepoya Dental College
Mangalore
Under the Guidance:
Dr Rohan Mascarenhas, Professor
Dr Akhter Husain, Professor & H.O.D
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3. INTRODUCTION
Greek word apnea, which means "without breath."
serious sleep disorder
stop breathing for 10 to 30 seconds at a time
short stops in breathing can happen up to 400 times every
night
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4. INTRODUCTION
Obstructive Apnea-a cessation of airflow-at least 10 s w/
continued effort to breathe
Central Apnea-apnea w/ no effort to breathe
Mixed Apnea-apnea begins as central but towards end there is
effort to breathe without airflow
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6. RISK FACTORS
Excessive weight gain
accumulation of fat on the sides of the upper airway causes
it to become narrow and predisposed to closure when the
muscles relax
Age
Loss of muscle mass is a common consequence of the
aging process
Men have a greater risk for OSA
Male hormones can cause structural changes in the upper
airway
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7. RISK FACTORS
Anatomic abnormalities, such as a mandibular retrognathia
Enlarged tonsils and adenoids, the main causes of OSA in
children
Family history of OSA, although no genetic inheritance pattern
has been proven
Use of alcohol and sedative drugs, which relax the musculature
in the surrounding upper airway
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8. RISK FACTORS
Smoking, which can cause inflammation, swelling, and
narrowing of the upper airway
Enlarged tongue - Hypothyroidism, Acromegaly, Amyloidosis,
Vocal cord paralysis, Post-polio syndrome, Neuromuscular
disorders, Marfan's syndrome, and Down syndrome
Nasal congestion
While obesity is clearly a risk factor for sleep apnea, sleep apnea is
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multi-factorial and occurs among people in all weight category.
13. SYMPTOMS
Loud snoring
Excessive daytime sleepiness
Falling asleep easily and sometimes inappropriately
High blood pressure
Other cardiovascular complications
Morning headaches
Memory problems
Feelings of depression
Reflux
Nocturia
Impotence
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14. OSAHS – Diagnosis
The following questions should be asked whenever a diagnosis
of OSAHS is being considered
Is the patient falling asleep regularly against their will?
Is this patient often sleepy whilst driving?
Is this patient experiencing difficulties at work because of
excessive sleepiness?
Is surgery for snoring being contemplated?
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15. THE EPWORTH SLEEPINESS
SCALE
How likely are you to doze off or fall asleep in the following
situations in contrast to just feeling tired? This refers to your
usual way of life in recent times. Even if you have not done
some of these things, try to work out how they would have
affected you.
Use the following scale to choose the most appropriate number
for each situation.
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
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16.
Situation Chance of Dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g.. a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances
permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL (max. 24)
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17. OSAHS – Diagnosis
Epworth Sleepiness Scale – a validated method of assessing
the likelihood of falling asleep in a variety of situations
Mild daytime sleepiness – ESS 11 – 14
Moderate daytime sleepiness – ESS 15-18
Normal – ESS <11
Severe daytime sleepiness – ESS >18
Correlation between ESS and OSAHS is relatively weak, but
gives a guide to the patients perception of his/her sleepiness
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18. OSAHS – Diagnostic Tools
Full Polysomnography
Costly and complex
Investigation of choice for a minority of patients
Limited sleep studies
Cost effective, convenient for patients, speeds up the
investigation pathway
Overnight sleep studies
A good screening tool
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19. Overnight Polysomnography
Electro-encephalography (EEG) - brain wave monitoring
Electromyography (EMG) - muscle tone monitoring
Recording thoracic-abdominal movements - chest and
abdomen movements
Recording oro-nasal airflow - mouth and nose airflow
Pulse oximetry - heart rate and blood oxygen level monitoring
Electrocardiography (ECG) - heart monitoring
Sound and video recording
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21. Polysomnographic Criteria For OSA
Criteria
Adults
Children
(one to 12
years of age)
Apnea-Hypopnea Index*
>5
>1
Minimum Oxygen Saturation (%)
<85
<92
The apnea- hypopnea index is the average number of apneas
and hypopneas per hour of sleep
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22. OSAHS - Severity
Measured using the apnoea/hypopnoea index (AHI) or the
respiratory disturbance index (RDI)
Mild – AHI 5 – 14 / hour
Moderate – AHI 15 – 30 / hour
Severe – AHI > 30 / hour
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24. OSAHS – Treatment
Behavioural interventions
May be sufficient in simple snorers or in those with very mild
OSAHS and few symptoms
Weight loss in obese patients
Alcohol and sedatives should be avoided
Non-sleepy snorers should be discouraged from sleeping on
their backs
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25. OSAHS – Treatment
CPAP
Pneumatic splint to maintain upper airway patency
throughout all phases of sleep
Treatment of choice
Improves subjective and objective sleepiness, cognitive
function, vigilance, mood and quality of life measures.
Best results are obtained in those with an AHI of >15
Side effects: epistaxis, sinusitis, rhinitis, dryness of the
nasal passages, nasal bridge sores, claustrophobia,
abdominal bloating, mouth leaks and noise
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31. Anterior Tongue Repositioners
advances the tongue
tongue & mandible together with adjacent soft tissue
increases the posterior airway space
increases the activity of the genioglossal & lateral pterygoid
muscles
effects a stretch induction of the pharyngeal motor system
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39. Soft Palate or Uvula Lifting Devices
reduce soft tissue vibrations that result in snoring
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40. Best????
Although there are logical clinical reasons for using different
appliances, there is not enough scientific evidence for the
clinician to determine which appliance is most likely to improve
symptoms for a given patient
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41. Consequences of untreated OSAHS
Six fold increase in RTA (20% due to sleepiness at the wheel)
Impairment of cognitive function
Impairment of mood
Personality changes
Reduction in quality of life
Impaired relationships
Increased risk of hypertension, IHD and strokes
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42. Conclusion
Dental professionals can, and should, play an active role in
screening patients for the disease
&
providing oral appliance therapy (OAT) when a sleep
specialist physician has prescribed it
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