Dental Screening in OSA- what to look for Jennifer Buchanan, DDS - - PowerPoint PPT Presentation

Dental Screening in OSA- what to look for

Jennifer Buchanan, DDS Diplomate, American Board of Orofacial Pain Assistant Clinical Professor, UCSF private practice, San Rafael, California jennifer.buchanan@ucsf.edu

potential conflict of interest: none

I am a consultant for Sleep Science Partners

Orofacial Pain Specialist:

• Orthopedic issues: Temporomandibular Disorders
• Headache
• Neuropathic pain
• Dental Diagnosis

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Mandibular Advancement Devices

“Herbst” “EMA”

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My Dad

FTP I FTP IIA FTPIIB

FTP III FTP IV

Friedman, M, et al., Laryngoscope. (1999) 109;1901-1907 Friedman,M, et al., Otolaryngol Head Neck Surg (2013)148;540-547

grading of tonsils

soft tissues: tongue size tonsil size

• ropharyngeal width

Just another day at the Orifice!

Schwab, RJ, et al., Chest (2017);152;330-342

tongue scalloping “crenations”, “ridging”

Weiss, Atanasov, Calhoun, Otolaryngol Head Neck Surg (2005);133;966-971

Risk factors independent

• f BMI:

maxillary insufficiency posterior and inferior hyoid bone Associated with: retrognathia long and narrow face

Hard tissues: craniofacial skeletal structures

Dempsey, JA, Skatrud, JB, Jacques, AJ, et al., CHEST 2002 122(3):840-851 Riha, RL, et al., SLEEP 2005; 28(3): 315-320 Finkelstein, Y, et al., Laryngoscope. 2001; 111:634-641 Paoli, JR, et al., Br J Oral Maxilfac Surg. 2001 Feb;39(1):40-5. Guillemenault, CR, et al., CHEST 1984 86(5):793–794

retrognathic; overbite (horizontal overlap)

Tsai,WH, et al., AJRCCM (2003); 167;1427-1432 Paoli, JR, et al., Br J Oral Maxilfac Surg. 2001 Feb;39(1):40-5. Guillemenault, CR, et al., CHEST 1984 86(5):793–794

deep bite (vertical overlap)

Tsai,WH, et al., AJRCCM (2003); 167;1427-1432

photograph courtesy of Dennis Bailey, DDS

high narrow palate posterior crossbite

Dempsey, JA, et al., Chest (2002);122;840-851 Poirrier, AL, Laryngoscope 2012 Oct;122(10):2350-4

Anterior open bite Posterior Crossbite (maxillary insufficiency)

Dempsey,JA, et al., Chest (2002);122;840-851

photograph courtesy of Dennis Bailey, DDS

prognathic:maxillary insufficiency

Dempsey,JA, et al., Chest (2002);122;840-851

Periodontal Disease correlates with SDB:

Sanders, Essick, Beck, et al., SLEEP (2015); 38;1195-1203 Famili, P. J Dent Oral Health (2015); 1;1-4 Gunaratnam, Taylor, Curtis, Cistulli, Sleep Breath (2009); 13(3):233-239

Carotid Artery Calcifications and OSA

Friedlander, et al., J Oral Max Surg (1998) 56;950-954

panograph courtesy of David Hatcher, DDS

“So, How’s your sleep?”

• How%long%do%you%sleep?%
• When%do%you%go%to%bed,%when%do%you%wake%up?
• Do%you%have%trouble%falling%asleep/staying%

asleep?

• Do%you%feel%rested%and%refreshed%when%you%

wake?

• Do%you%feel%tired%during%the%day?
• Do%you%snore?

TMD and SDB:

arthritic changes in the TMJ create the anatomic correlates that are risk factors for SDB

Temporomandibular Disorders

TMD and Sleep Disorders:

Increase in OSA and insomnia in patients with myofascial pain

Smith, MT, et al., SLEEP, 2009; 32(6): 779-790

• a significant but mild increase in stage N1 sleep
• mild but significant elevations in RERAs and arousals

associated with all types of respiratory events

• TMD patients with pain on the night of PSG had lower sleep

efficiency, more frequent awakenings and higher RERAs

Dubrovsky, B, Raphael, K, LeVigne, G, et al., JCSM, 2014; 10(2):195-201

Adenoidal faces, mouth breathing

Schlenke ker, WL e al., J J Or Orth thod De Dent Or Orth thop 2000 Ju Jun;117(6):706-13 13 Li Lind nder er-Aronso son, S, Ac Acta Otolaryn yngol Su Suppl ppl.1 .1970;2 ;265:1 :1-132 132

Dentists are uniquely qualified to evaluate craniofacial development and structures

age 8 years age 12 years

Intervention requires a team: Pediatrician Otolaryngologist Allergist Orthodontist

why do they fail?

• uncomfortable to wear

(jaw feels worse)

• bite changes
• it didn’t work
• restorative sleep
• jaw feels better
• no more snoring

why do they work?

Sc Screening g the Pa Patient for Or Oral Appl Appliance Therapy py

• 1. opens the vertical dimension of occlusion
• 2. advances the mandible

what does an oral appliance do?

The effects of an oral appliance on the airway

Good Candidates: anatomic factors

dilation of the upper pharyngeal airway reducing airway collapse

History includes:

• Sleep history
• medical history
• jaw pain, jaw noises
• neck pain, headache

Can you stand to wear an appliance?

• gagging
• tooth sensitivity
• muscle pain
• joint pain

Generally (but not universally) More Success With:

• Younger
• Lower BMI, smaller neck circumference
• Mild-moderate OSA
• Supine predominant
• Retrognathic, lower hyoid position
• Decent nasal airway

Sutherland, K, et al., JCSM (2014);10;215-227 Zeng, B, et al., SLEEP (2008);31;543-547

Exam

• Muscle tenderness
• Mandibular range and quality of motion
• Joint findings: DJD? Disc disorder?
• soft tissues, tongue size, pharyngeal space
• response to mandibular repositioning (George

Gauge)

subjective testing of the airway: The George Gauge

• subjective sense of airway improved
• snore sound diminished or eliminated
• lip seal preserved
• minimal mandibular advancement

Not necessarily a contraindication for OAT

The TMJ:

the TMD patient and OAT

• need a good range of motion
• joint noises- crepitus? click?
• test joint loading for capsule

inflammation

• radiographs
• start with vertical change,

slowly advance to efficacy

evaluate dentition

• number of teeth
• periodontal disease
• tooth decay
• existing restorations
• occlusion

The Edentulous Patient: maintain or increase vertical dimension

• wear their denture at night
• fabricate an appliance to go over their denture
• fabricate an appliance for night time wear- open

the vertical, slightly advance the mandible, anterior space for the tongue

photograph courtesy of Dennis Bailey, DDS

Edentulism and Worsening of Obstructive Sleep Apnea, The Lancet 1999; 353:121 Association of Denture Use with Sleep-Breathing among older adults, J Public Health Dent 2004; 64(3):181-183

Preventing bite changes:

• allow mandibular mobility with OA design
• address bite changes right away
• bite changes should last no more than a few

hours in the morning

• jaw massage, “tongue-up” stretching

exercises

• at delivery fabricate a soft ‘repositioner’ to bite
• n

Nasal Airway Resistance

For best results, evaluate and treat the patient for:

• alar rim collapse
• allergies, rhinitis
• large turbinates
• deviated septum
• mouth breathing
• etc.

Zeng, B, et al., SLEEP (2008);31;543-547

Upper Airway Collapsibility and Loop Gain: Edwards, Andara, Landry, et al., AJRCCM (2016) 194;1413-1422

anatomic factors are not the whole story:

with thanks to Dennis Bailey, DDS and David Hatcher, DDS