Obstructive Sleep Apnea : Role Of Oral Appliances , Dr. Abhishek S. Bendale, BDS, MDS,( Post-Graduate Student ) E-mail ID : abhishek.bendale@gmail.com Mobile No.: 9503 870975. Dr. Sangeeta A. Golwalkar, BDS, MDS.( Professor and HOD ) Dept. Of Orthodontics And Dentofacial Orthopedics Tatyasaheb Kore Dental College And Research Centre Kolhapur- 416 137, Maharashtra, India. INTRODUCTION “Sleep is a reward for some, a punishment for others”- Issador Ducasse Sleep disordered breathing (SDB) includes a spectrum of conditions, the most severe of which is obstructive sleep apnea syndrome (OSAS). It is a potentially disabling condition characterised by disruptive snoring, repeated episodes of complete or partial pharyngeal obstruction during sleep resulting in nocturnal hypoxemia, frequent arousals and excessive daytime sleepiness. Among adults, sleep apnea is more common than asthma. Recognised as a separate clinical entity nearly 35 years ago, OSA still remains a substantial but frequently ignored public health threat. These apneic episodes can last from 10 to 120 seconds. Apnea severity is categorized by the frequency of apnea events that occur per hour. This number is called the apnea index1. It is not unusual for a patient with severe apnea to have as many as 300 episodes per night. There are three basic classifications of sleep apneas1, i.e., Central apnea Obstructive sleep apnea Mixed apnea Apnea is defined as complete cessation of nasal airflow for more than 10 seconds 2. EPIDEMIOLOGY Several global epidemiological studies3-4 have demonstrated a variable prevalence of OSAS (0.3 to 5.1%). Major etiological factors such as obesity and craniofacial anatomical predispositions are both genetically and environmentally influenced. Estimates of OSAS prevalence in Asian population are similar5(2-4%). SYMPTOMS The symptoms of OSA can be very revealing. The obvi­ous one is, of course, snoring, but some less obvious symptoms include daytime sleepiness, impaired intellec­tual function, insomnia, depression, irritability, and poor workplace performance. As noted before, OSA can be a fatal disease if left undiagnosed. This is primarily due to the circulation of unsaturated blood during the night, which can cause cardiopulmonary changes, congestive heart failure, and strokes. Daytime sleepiness can also lead to fatal motor vehicle accidents. DIAGNOSIS So how does an orthodontist participate in the diagnosis of OSA? If a patient is suspected of having OSA, the diagnosis is confirmed by an overnight polysomnography (PSG), commonly referred to as a sleep study. If a patient visits the orthodontist asking for an oral appliance to alleviate snoring, an Orthodontist recommends discussing the possibility of OSA with the patient and recommending a PSG to confirm the diagnosis. Communicate this recommendation to the patient’s physician. TREATMENT The guideline for treating mild cases of OSA include increasing the hours of night sleep to eight, weight reduc­tion, sleep posture training, avoiding any CNS depressants including prescription medications, and oral appliances, which can be very effective in treating mild cases. Nonspecific Therapy These measures should be included in patients with very mild apnea whose main complaint is snoring. Overweight persons can benefit from losing weight.6http://bit.ly/10tqXIS – ref1 Individuals with apnea should avoid alcohol four to six hours prior to bedtime and also sleeping pills, which might collapse the airway during sleep and prolong the apneic periods. Positional therapy can be used to treat patients whose OSA is related to body positioning during sleep. 7 Specific Therapy The specific therapy for sleep apnea is based on medical history, physical examination and the results of polysomnography. Medications are generally not effective in the treatment of sleep apnea. Surgery Historically, surgical procedures used for management of OSA have included intranasal procedures, reduction glossectomies, uvulopalatopharyngoplasty procedures and tracheostomy. Oral Appliances Oral appliances were originally derived from an orthodontic functional appliance, the Esmarch appliance, as proposed by Meyer-Ewert and Brosik.8 It has been variously modified with the aim of increased effectiveness and patient compliance for intra-oral use. Of the several appliances available in the market today, more than 34 have been accepted by the American Food and Drug Administration for intraoral use in the treatment of obstructive sleep apnea. The appliances can be broadly classified into: Tongue repositioning devices, such as the tongue retaining device Mandibular advancement devices (MAD) which work by holding the lower jaw and the tongue forward during sleep Devices designed to lift the soft palate or reposition the uvula Uvula lifters, which are not in use now due to discomfort. Tongue Retaining Devices The tongue retaining device was first developed by a physician in 1979. It is a bubble shaped device made of soft polyvinyl. The patient’s teeth rest in custom fitted grooves which are extended to form a ‘bubble’ that sticks out from between the lips. The patient positions his teeth in the grooves, sticks his tongue forward into the bubble until suction grabs and holds the tongue in place. Positioning the tongue forward may eliminate any obstruction caused by the base of the tongue. 9 Mandibular Advancement Devices MAD essentially consist of a plastic mould of the teeth. Advancement of the lower teeth moves the mandible forward and opens the airway, preventing its collapse during sleep.10 Relatively simple. Reversible and Cost effectiveness. Complications of MAD could be loosened teeth, joint pain, muscle aches, tissue sores, inability to touch the posterior teeth together when the appliance is first removed in the morning, permanent tooth movement and excessive salivation. Studies have shown that long-term use of appliances which moved the jaw forward result in permanent tooth repositioning in as many as 20% of patients. Hence, frequent check- ups after giving the oral appliances is very essential. Appliance Designs Silencer System This appliance incorporates titanium precision attachments at the incisor level, allowing sequential 2 mm advancement of up to 8 mm, lateral movement of 6 mm, 3 mm bilaterally and vertical pin height replacements. It is the only appliance that allows adjustment in not only an antero-posterior, but also in an ‘open and closed’ position. As it includes a very expensive titanium metal hinge device. Klearway Oral Appliance The Klearway oral appliance utilizes a maxillary orthodontic expander to sequentially move the mandible forward. Klearway is a fully adjustable oral appliance used for the treatment of snoring and mild to moderate OSA. Small increments of mandibular advancement are initiated by the patient and this prevents rapid jaw movements that cause significant patient discomfort. PM Positioner The PM positioner links the upper and lower splints with bilateral orthodontic expanders. This appliance is made of a thermoplastic material which must be heated in hot tap water every night before it is placed in the mouth. Thornton Adjustable Positioner The Thornton adjustable positioner (TAP) allows for progressive Ό mm advancements of the jaw via an anterior screw mechanism at the labial aspect of the upper splint. This appliance has a separate section for the mandible and maxilla. Modified Herbst Appliance This appliance design links upper and lower splints with a piston-post and sleeve adjustable telescopic mechanism on each side. It prevents side-to-side motion, but since the mandible is held closed with small orthodontic rubber bands, opening the the jaws is fairly easy. The Elastic Mandibular Advancement The elastic mandibular advancement (EMA) is the thinnest and least bulky of all the appliances. It is similar to clear acrylic orthodontic retainers, and moves the jaw forward in fairly significant steps, and can be difficult to tolerate. Conclusion As dental professionals, we have a significant role to play in the early diagnosis, management and care of patients suffering from sleep apnea. Many treatment approaches have been used in the management of this condition. The long term success rates of these procedures are yet to be documented in the literature. Oral appliances play a major role in the non-surgical management of OSA and have become the first line of treatment in almost all patients suffering from OSA. Of all the oral modalities of treatment, CPAP is considered to be the most effective for management of OSA. However, future randomized control trials are needed to compare the effectiveness of different oral appliances. REFERENCES Rob W Veis. Snoring and Obstructive Sleep Apnea from a Dental Perspective. J Calif Dent Assoc. 1998 Aug;26(8):557-65. American Academy of Sleep Medicine. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine task force. Sleep 1999; 22: 667-89. Gislason T, Almqvist M, Eriksson G, Taube A, Boman G.Prevalence of sleep apnea syndrome among Swedish men: an epidemiological study. J Clin Epidemiol 1988; 41: 571-6. Ancoli-Israel S, Kripke D, Klaube MR, Mason WJ, Fell R, Kaplan O. Sleep disordered breathing in community dwelling elderly. Sleep 1991; 14: 486-95. Udwadia ZF, Doshi AV, Lonkar SG , Singh CI. Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med 2004; 169: 168-73. Smith PL, Gold AR, Meyers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med 1985;103:850-55. Thornton WK, Roberts DH. Nonsurgical management of the obstructive sleep apnea patient. J Oral Maxillofac Surg 1996;54:1103-8. Meyer-Ewert K, Brosik B. Treatment of sleep apnea by prosthetic mandibular advancement. Sleep related disorders and internal medicine. Berlin: Springer-Verlag; p. 341-5 as cited in Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnea. Eur J Orthod 2002;24:191-8. George PT. A modified functional appliance for treatment of obstructive sleep apnea. J Clin Orthod 1987;21:171-5. Liu Y, Zeng X, Fu M, Huang X, Lowe AA. Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000;118:248-56. , http://bit.ly/1318Or5

Obstructive Sleep Apnea : Role Of Oral Appliances , Dr. Abhishek S. Bendale, BDS, MDS,( Post-Graduate Student ) E-mail ID : abhishek.bendale@gmail.com Mobile No.: 9503 870975. Dr. Sangeeta A. Golwalkar, BDS, MDS.( Professor and HOD ) Dept. Of Orthodontics And Dentofacial Orthopedics Tatyasaheb Kore Dental College And Research Centre Kolhapur- 416 137, Maharashtra, India. INTRODUCTION “Sleep is a reward for some, a punishment for others”- Issador Ducasse Sleep disordered breathing (SDB) includes a spectrum of conditions, the most severe of which is obstructive sleep apnea syndrome (OSAS). It is a potentially disabling condition characterised by disruptive snoring, repeated episodes of complete or partial pharyngeal obstruction during sleep resulting in nocturnal hypoxemia, frequent arousals and excessive daytime sleepiness. Among adults, sleep apnea is more common than asthma. Recognised as a separate clinical entity nearly 35 years ago, OSA still remains a substantial but frequently ignored public health threat. These apneic episodes can last from 10 to 120 seconds. Apnea severity is categorized by the frequency of apnea events that occur per hour. This number is called the apnea index1. It is not unusual for a patient with severe apnea to have as many as 300 episodes per night. There are three basic classifications of sleep apneas1, i.e., Central apnea Obstructive sleep apnea Mixed apnea Apnea is defined as complete cessation of nasal airflow for more than 10 seconds 2. EPIDEMIOLOGY Several global epidemiological studies3-4 have demonstrated a variable prevalence of OSAS (0.3 to 5.1%). Major etiological factors such as obesity and craniofacial anatomical predispositions are both genetically and environmentally influenced. Estimates of OSAS prevalence in Asian population are similar5(2-4%). SYMPTOMS The symptoms of OSA can be very revealing. The obvi­ous one is, of course, snoring, but some less obvious symptoms include daytime sleepiness, impaired intellec­tual function, insomnia, depression, irritability, and poor workplace performance. As noted before, OSA can be a fatal disease if left undiagnosed. This is primarily due to the circulation of unsaturated blood during the night, which can cause cardiopulmonary changes, congestive heart failure, and strokes. Daytime sleepiness can also lead to fatal motor vehicle accidents. DIAGNOSIS So how does an orthodontist participate in the diagnosis of OSA? If a patient is suspected of having OSA, the diagnosis is confirmed by an overnight polysomnography (PSG), commonly referred to as a sleep study. If a patient visits the orthodontist asking for an oral appliance to alleviate snoring, an Orthodontist recommends discussing the possibility of OSA with the patient and recommending a PSG to confirm the diagnosis. Communicate this recommendation to the patient’s physician. TREATMENT The guideline for treating mild cases of OSA include increasing the hours of night sleep to eight, weight reduc­tion, sleep posture training, avoiding any CNS depressants including prescription medications, and oral appliances, which can be very effective in treating mild cases. Nonspecific Therapy These measures should be included in patients with very mild apnea whose main complaint is snoring. Overweight persons can benefit from losing weight.6http://bit.ly/10tqXIS – ref1 Individuals with apnea should avoid alcohol four to six hours prior to bedtime and also sleeping pills, which might collapse the airway during sleep and prolong the apneic periods. Positional therapy can be used to treat patients whose OSA is related to body positioning during sleep. 7 Specific Therapy The specific therapy for sleep apnea is based on medical history, physical examination and the results of polysomnography. Medications are generally not effective in the treatment of sleep apnea. Surgery Historically, surgical procedures used for management of OSA have included intranasal procedures, reduction glossectomies, uvulopalatopharyngoplasty procedures and tracheostomy. Oral Appliances Oral appliances were originally derived from an orthodontic functional appliance, the Esmarch appliance, as proposed by Meyer-Ewert and Brosik.8 It has been variously modified with the aim of increased effectiveness and patient compliance for intra-oral use. Of the several appliances available in the market today, more than 34 have been accepted by the American Food and Drug Administration for intraoral use in the treatment of obstructive sleep apnea. The appliances can be broadly classified into: Tongue repositioning devices, such as the tongue retaining device Mandibular advancement devices (MAD) which work by holding the lower jaw and the tongue forward during sleep Devices designed to lift the soft palate or reposition the uvula Uvula lifters, which are not in use now due to discomfort. Tongue Retaining Devices The tongue retaining device was first developed by a physician in 1979. It is a bubble shaped device made of soft polyvinyl. The patient’s teeth rest in custom fitted grooves which are extended to form a ‘bubble’ that sticks out from between the lips. The patient positions his teeth in the grooves, sticks his tongue forward into the bubble until suction grabs and holds the tongue in place. Positioning the tongue forward may eliminate any obstruction caused by the base of the tongue. 9 Mandibular Advancement Devices MAD essentially consist of a plastic mould of the teeth. Advancement of the lower teeth moves the mandible forward and opens the airway, preventing its collapse during sleep.10 Relatively simple. Reversible and Cost effectiveness. Complications of MAD could be loosened teeth, joint pain, muscle aches, tissue sores, inability to touch the posterior teeth together when the appliance is first removed in the morning, permanent tooth movement and excessive salivation. Studies have shown that long-term use of appliances which moved the jaw forward result in permanent tooth repositioning in as many as 20% of patients. Hence, frequent check- ups after giving the oral appliances is very essential. Appliance Designs Silencer System This appliance incorporates titanium precision attachments at the incisor level, allowing sequential 2 mm advancement of up to 8 mm, lateral movement of 6 mm, 3 mm bilaterally and vertical pin height replacements. It is the only appliance that allows adjustment in not only an antero-posterior, but also in an ‘open and closed’ position. As it includes a very expensive titanium metal hinge device. Klearway Oral Appliance The Klearway oral appliance utilizes a maxillary orthodontic expander to sequentially move the mandible forward. Klearway is a fully adjustable oral appliance used for the treatment of snoring and mild to moderate OSA. Small increments of mandibular advancement are initiated by the patient and this prevents rapid jaw movements that cause significant patient discomfort. PM Positioner The PM positioner links the upper and lower splints with bilateral orthodontic expanders. This appliance is made of a thermoplastic material which must be heated in hot tap water every night before it is placed in the mouth. Thornton Adjustable Positioner The Thornton adjustable positioner (TAP) allows for progressive Ό mm advancements of the jaw via an anterior screw mechanism at the labial aspect of the upper splint. This appliance has a separate section for the mandible and maxilla. Modified Herbst Appliance This appliance design links upper and lower splints with a piston-post and sleeve adjustable telescopic mechanism on each side. It prevents side-to-side motion, but since the mandible is held closed with small orthodontic rubber bands, opening the the jaws is fairly easy. The Elastic Mandibular Advancement The elastic mandibular advancement (EMA) is the thinnest and least bulky of all the appliances. It is similar to clear acrylic orthodontic retainers, and moves the jaw forward in fairly significant steps, and can be difficult to tolerate. Conclusion As dental professionals, we have a significant role to play in the early diagnosis, management and care of patients suffering from sleep apnea. Many treatment approaches have been used in the management of this condition. The long term success rates of these procedures are yet to be documented in the literature. Oral appliances play a major role in the non-surgical management of OSA and have become the first line of treatment in almost all patients suffering from OSA. Of all the oral modalities of treatment, CPAP is considered to be the most effective for management of OSA. However, future randomized control trials are needed to compare the effectiveness of different oral appliances. REFERENCES Rob W Veis. Snoring and Obstructive Sleep Apnea from a Dental Perspective. J Calif Dent Assoc. 1998 Aug;26(8):557-65. American Academy of Sleep Medicine. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine task force. Sleep 1999; 22: 667-89. Gislason T, Almqvist M, Eriksson G, Taube A, Boman G.Prevalence of sleep apnea syndrome among Swedish men: an epidemiological study. J Clin Epidemiol 1988; 41: 571-6. Ancoli-Israel S, Kripke D, Klaube MR, Mason WJ, Fell R, Kaplan O. Sleep disordered breathing in community dwelling elderly. Sleep 1991; 14: 486-95. Udwadia ZF, Doshi AV, Lonkar SG , Singh CI. Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med 2004; 169: 168-73. Smith PL, Gold AR, Meyers DA, Haponik EF, Bleecker ER. Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med 1985;103:850-55. Thornton WK, Roberts DH. Nonsurgical management of the obstructive sleep apnea patient. J Oral Maxillofac Surg 1996;54:1103-8. Meyer-Ewert K, Brosik B. Treatment of sleep apnea by prosthetic mandibular advancement. Sleep related disorders and internal medicine. Berlin: Springer-Verlag; p. 341-5 as cited in Rose E, Staats R, Virchow C, Jonas IE. A comparative study of two mandibular advancement appliances for the treatment of obstructive sleep apnea. Eur J Orthod 2002;24:191-8. George PT. A modified functional appliance for treatment of obstructive sleep apnea. J Clin Orthod 1987;21:171-5. Liu Y, Zeng X, Fu M, Huang X, Lowe AA. Effects of a mandibular repositioner on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 2000;118:248-56. , http://bit.ly/1318Or5 , via Dental Teach " Daily Dental Info " http://www.facebook.com/photo.php?fbid=588953117795908&set=a.588953107795909.1073741858.110664842291407&type=1