Obstructive Sleep Apnea Flashcards
(85 cards)
1
Q
what are the recommendations for OSA treatment with oral appliance therapy
A
- sleep physicians prescribe oral appliances rather than no therapy, for adult patients who request treatment of primary snoring with OSA
- when oral appliances are prescribed for an adult pt with OSA, a qualified dentist should use a custom, titratable appliance over non custom oral devices
- sleep physicians should consider prescription of oral appliances rather than no treatment
- dentists should provide oversight to survey for dental related side effects or occlusal changes
- sleep physicians should conduct follow up sleep testing to improve or confirm treatment efficacy
- pt should return for periodic office visits with a qualified dentist
2
Q
what are the 3 types of sleep apnea
A
- obstructive
- central
- mixed
3
Q
describe obstructive sleep apnea
A
absence of airflow despite respiratory effort
4
Q
describe central sleep apnea and how is it treated
A
absence of airflow and no respiratory effort (brain control respiration is abnormal)
- treated by MD with meds
5
Q
what is mixed sleep apnea
A
combination of obstructive and central
6
Q
which type of sleep apnea may a dentist treat
A
obstructive
7
Q
who treats OSA
A
- NOT pre-doctoral students or residents
- treated by a general dentist who is certified in sleep medicine with knowledge of medical billing. CE coursework is required to treat OSA
8
Q
dx of OSA must be made by:
A
a licensed physician and a polysomnogram sleep study must be ordered by the MD as well as treatment studies
9
Q
OSA dx requires:
A
- a national provider identification number and dental license to bill for this medical condition
- requires advanced training to TREAT and interpret the sleep studies to determine efficacy of sleep appliance
10
Q
what is OSA
A
- very common and potentially life threatening medical disorder
- occurs when tissue in the back of the throat collapses and blocks the airway, reducing the amount of oxygen delivered to all of your organs including your heart and brain
11
Q
what is the definition of apnea
A
cessation of oronasal airflow for 10 seconds or more
12
Q
what is the definition of hypopnea
A
decrease in airflow of 50% for more than 10 seconds with less than 3% O2 desaturation
13
Q
what is apnea index
A
the average number of apneas per hour of sleep
14
Q
what is apnea- hypopnea index
A
the average number of apneas and hypopneas per hour of sleep
15
Q
what is respiratory disturbance index
A
AHI and RERAs (respiratory effort related arousals)
16
Q
what requires treatment
A
AHI > 5, respiratory disturbance index is elevated
17
Q
what is oxygen saturation
A
the fraction of a total hemoglobin in the form of HbO2 at a defined pressure of oxygen
18
Q
what is the partial pressure of arterial oxygen
A
- the part of total blood gas pressure exerted by oxygen gas. normal partial pressure of oxygen in arterial blood is 95-100mg. it is lower in individuals with asthma, obstructive lung disease and certain blood diseases
19
Q
what is normal SaO2 in awake individual
A
higher than 93%
20
Q
what is mild SaO2 desaturation in OSA
A
85-89%
21
Q
what is moderate SaO2 desaturation in OSA
A
80-84%
22
Q
what is severe SaO2 desaturation in OSA
A
less than 80%
23
Q
certain individuals with OSA will experience decreased O2 saturations causing:
A
hypoxia during sleep
24
Q
decreased SaO2 levels below 80% are known to:
A
compromised organ function
25
continued low oxygen levels may lead to:
respiratory or cardiac arrest. atrial fibrillation is common
26
what is the epidemiology of OSA
- affects 4% of adult population in the US
- male: female prevalence is 2-3:1
- occurs 2x more frequently due to progesterone levels in menopause
- 10% insomnia
- increases with middle age
- increases with high BMI
27
what is the incidence of snoring by age 40 in males and females
- males: 40%
- females: 20%
28
what is the incidence of snoring by age 60 in males and females
- males: 60%
- females; 40%
29
snorers have an increased risk of what for the following conditions: HTN, sudden death, CVAs, and ischemic heart disease
- HTN: 2x
- sudden death: 4X
- CVAs (stroke): 10x
- ischemic heart disease: 2x
30
what are the medical consequences of OSA
- death
- cardiovascular- HTN, MI, stroke
- diabetes, obesity, depression
- medical costs - 2.5- 3x hospital days and 2x medical costs
31
what is the personal impact of OSA
- motor vehicle accidents- corrects with CPAP
- psychosocial/economic failure- 34% fell asleep at work, 11% demoted or fired
- lost productivity and workplace accidents
32
what does the medical evaluation for OSA include
- history and epworth sleepiness scale
- physical exaM: neck size, BMI, ENT, evaluation
- polysomnogram with split night titration wearing the CPAP mask during 2nd half of study
- imaging: dynamic MRI may be done
- dental exam: TMD exam, pano, and/or lateral tomography or CBCT of TMJ
33
what are the primary signs of OSA
- snoring
- hypersomnia
- breathing pauses, choking
34
what are the secondary signs of OSA
- hypertension
- GERD
- night sweats
= headaches
- nocturia
- decreased libido and/or impotence
- decreased memory
- irritability
- atrial fibrillation
35
what are the overall symptoms of OSA
- daytime somnolence
- snoring
- chronic fatigue
- neurocognitive
- dysfunction
36
what is the role of dentists in OSA
- recognize OSA symptoms and refer to sleep physician
- manage possible consequences of OSA- bruxism, GERD and oro facial pain
- ability to recommend the appropriate mandibular advancement devices
- coordinate with a sleep physician and monitor the patients physical and mental health
- able to understand the results of sleep studies
- managing the possible side effects of using MADs
37
dentists should look for what in the mouth for OSA
- enlarged tonsils
- enlarged tongue
- elongated uvula
- decreased airway space
- when patient says AHH - elongated soft palate, V shaped palate, micrognathia/retrognathia
38
upper airway patency during sleep depends on:
- upper airway size and stiffness
- neuronal control of pharyngeal muscles
39
mallampati score of ______ is no airway space
class 4
40
if you observe _____ or _____ ask patient about snoring, gasping for air, poor sleep quality and daytime fatigue
restricted airway space or retrognathia
41
refer patient to physician for:
an evaluation and polysomnogram sleep study
42
MRI will demonstrate:
size and position of tongue and narrowing oropharynx
43
when is polysomnogram required
- prior to treatment
- at end of completion to determine efficacy of oral sleep apnea appliance although some insurance will accept the home sleep study
44
what does the polysomnography monitor
- sleep stages
- respiration
- oxygen saturation
- nasal and oral airflows
- electrocardiography
- electroencephalography
- sleep position
45
what are the clinical predictors for favorable response to mandibular advancement device
- younger age
- lower BMI
- lower neck circumference less than 17"
- positional OSA
- lower AHI (not consistenctly)
- increased protrusion
46
what are the craniofacial predictors for favorable response to mandibular advancement device
- larger oropharynx
- smaller overjet
- short soft palate length
47
what are the contraindications for sleep apnea devices
- insufficient teeth to support device however can be made if 1 arch is edentulous
- periodontal problems causing tooth mobility
- active TMJ or severe arthritis
- limited maximum protrusion less than 6mm
48
______ of drivers admit to falling asleep at the wheel
20%
49
sleep ranks among the _____ most important considerations in maintaining good health
3
50
______ of the US population experiences intermittent or regular sleep problems
62%
51
_______ of these adults with sleep problems have never discussed this with their physician
80%
52
what percentage of americans report sleep disorder symptoms
75%
53
vwhat percentage of americans report insomnia
33-54%
54
what percentage of americans report less than 7 hours sleep duration
40%
55
what percentage of americans report non restorative sleep
38%
56
what percentage of americans report snore nightly/weekly
32%
57
what percentage of americans report daytime fatigue and sleepiness
37%
58
what percentage of americans report driving while sleepy
60%
59
what percentage of americans report fatigue affects intimacy
20%
60
0-4 events per hour (AHI) is a ______ obstructive sleep apnea rating
no OSA
61
5-15 events per hour (AHI) is a ______ obstructive sleep apnea rating
mild
62
16-30 events per hour (AHI) is a ______ obstructive sleep apnea rating
moderate
63
more than 30 events per hour (AHI) is a ______ obstructive sleep apnea rating
severe
64
what is the diagnosis of sleep apnea based on
- spouse or family member reports snoring/apnea
- medical history OR HTN raises suscpicion
- dental exam reveals upper airway anatomical abnormalities
= degree of sleepiness can be assessed with a short questionnaire
65
what sleepiness scale is used
Epworth
66
what are the approved treatments for OSA
- CPAP (continuous positive airway pressure)/ Bilevel positive pressure (BiPAP)- gold standard
- ENT surgery - UVPP, tonsillectomy, deviated surgery, turbinectomy, genioglossus advancement or implanted nerve stimulator
- maxillomandibular advancement surgery
- mandibular advancement devices
- inspire neurostimulator that stimulates glossopharyngeal nerve to protrude tongue so airway space remains open
67
describe the CPAP
- splints the upper airway pneumatically during sleep so airway does not collapse
- highly effective but cumbersome
- long term compliance is 60-70%
68
what is the general treatment for OSA
- altering sleep position (raise head of bed)
- avoidance of alcohol, muscle relaxants and sedatives or narcotics
- relieving nasal congestion
- reducing weight
- smoking cessation
69
CPAP intolerance is due to
- claustrophobia
- mask leaks
- mask and tubing are bulky especially when changing sleep position
- must remove CPAP mask to use restroom
- contact dermatitis or allergy from mask
- embarrassment
70
what is uvulopalatopharyngoplasty
- surgical removal of uvula with resection of soft palate tissue to create more space
- 50% of patients report improved sleep apnea symptoms but not always long term
- surgery to correct deviated septum, nasal polyps, tonsillectomy and chronic rhinitis may also help
71
why are custom sleep apnea appliances are recommended
- numerous designs
- advance the mandible
- better tolerated by patients than CPAP
- better fit than soft appliances - OTC not recommended
- can create or exacerbate existing TMD
- can possibly create a malocclusion
- medical billing for appliance
72
what are the sleep apnea oral appliance terminologies
- mandibular advancement devices (MAD)- custom made by the dentist- fully adjustable
- oral appliance therapy (OAT)
- titratable thermoplastic devices (TPD)
- over the counter devices - NOT recommended- available directly to the patient (non-custom made) may not be titratable
73
________ is the most effective for patients with mild/moderate OSA
oral appliance therapy
74
OA therapy may also be efficacious for patients with:
severe OSA
75
how are CAD CAM sleep apnea appliances made
- the mandibular advancement device is custom made using a CAD CAM process
- use trios scanner or impressions/models upload scans into computer - send the dental lab
- design is milled on 3D printer by the dental lab using medical grade nylon or acrylic
76
only the _______ significantly reduced the AHI
custom appliances
77
failure rate with prefabricated (non-custom) devices was:
69%
78
______ of patients preferred the custom device
82%
79
what is the MOA of OA appliances
- normally made 50-75% of the maximum protrusion
- widening of the airway laterally
- relocation of the pharyngeal fat pads laterally
- anterior displacement of the tongue base
- protrusion is normally accompanies with increased vertical dimension
80
selection of types of titratable custom sleep apnea appliances may be based on the following:
- size of patient arch
- lack of sufficient undercuts (facial height of contour) to retain appliance
- number of missing teeth
- size/volume of appliance and size of mouth affect comfort
- patient preference
- patient allergy to acrylic or nickel - make SomnoMed Avant or Panthera sleep appliance
81
describe the AVANT sleep apnea appliance
- has nylon advancement rods that patient can change at home
- less driving and less appointments needed
- no metal
82
what are the appliance side effects
- too much or too little saliva
- irritation on cheeks or lips by fins or rods
- inability to close lips
- jaw pain
- feels like a mouth full
- change in occlusion in the morning or permanent
- gum pain
83
when are the follow up visits and what is done at that
- initially at 2-4 weeks and order treatment sleep study. every 6 months for the 1st year and then anually
- check compliance
- patient induced damages (due to modifications, bruxism)
- check oral health and occlusion and TMJ
- referral to a sleep physician as needed
84
what are the contraindications for sleep apnea devices
- insufficient teeth to support device but if good bone support can be made
- periodontal problems causing tooth mobility
- active TMD or severe arthritis
- limited maximum protrusion less than 6mm
85
