This presentation outlines sleep dentistry whiten the context of sleep medicine. Dr John Viviano DDS prepared this presentation to educate and encourage local dentists interested in the practice of Sleep Disorders Dentistry
2. Sleep Disorders Dentistry…
… the treatment of “Sleep Disordered Breathing”
Eg. Snoring, Sleep Apnea, UARS
Sleep Disordered Breathing is...
STILL often ignored by Primary Medical Care
Associated with Major Health Consequences
Dentists are...
ideally positioned to screen / refer / treat these disorders
3. Yearly Cost to Society (USA): Approaching $200 Billion
Sleep Disorders Dentistry…
5. Sleep Apnea found in…Sleep Apnea found in…
… 4% of men and 2% of Women (Age 40)
… Increases with each decade of life
… Higher in certain high risk groups
…78% of Long Distance Truck Drivers
…Highest on-the-job mortality of all professions
Snoring found in…Snoring found in…
… 40% of men and 20% of women
… Increases with each decade
Sleep Disorders Dentistry…
6. With “Sleep Disordered Breathing”…
The airway narrows or collapses
Interfering with breathing during sleep
Occurs at various levels of the airway
Net Result…
Snoring
Soft Tissue Vibration
Soft Palate, Uvula, Tongue, Airway Walls etc
Sleep Apnea
Airway Narrows or Collapses may have Blood
O2 Desaturation
UARS
Airway Narrows: extra effort required to
breathe causing arousals from sleep
.
Sleep Disorders Dentistry…
7. Why me…
Narrowing of the upper air-passages
Reduced airway muscle tone
Nasal obstruction
Obesity
Drugs
Alcohol
Fatigue
Smoking
Heredity
Sleep Disorders Dentistry…
8. Important Terminology
Apnea: Breathing stops for 10 seconds or longer
Hypopnea: 50% in airflow and⇓ 4% in blood O⇓ 2
RERA: Respiratory Effort Related Arousal
Apnea Index (AI)
Number of Apneas / hour of sleep
Apnea Hypopnea Index (AHI)
Number of Apneas + Hypopneas / hour of sleep
Respiratory Disturbance Index (RDI)
Number of Apnea + Hypopneas + RERAs / hour of sleep
Sleep Disorders Dentistry…
9. Spectrum of Disease & Recommended Therapy
as per American Academy of Sleep Medicine Sleep 2006
Snoring
UARS (Sleepy Snorer)
Mild Sleep Apnea (5-15 Events/hour)
Moderate Sleep Apnea (15-30 Events/hour)
Severe Sleep Apnea (Over 30 Events/hour)
Sleep Disorders Dentistry…
10. Typical Screening Questions…
How Restful or Restless is your Sleep?
How often do you Awaken during your Sleep Period?
Witnessed Apneas?
Witnessed Snoring?
Do you Awaken Tired?
Daytime Fatigue?
Do you have Morning Headaches
.
Sleep Disorders Dentistry…
12. Only a Physician can Diagnose these disorders…
Usually after having a Sleep Study…
Provides Objective Measurement of…
Apnea
Snoring
Blood Oxygen
Arousals from sleep
Breathing Patterns
…and much more
.
Sleep Disorders Dentistry…
15. Positional Therapy…
For some, Apnea is worse when sleeping on back; gravity makes
it more likely for the tongue to fall back into airway and tissues to
collapse and block the airway.
Sew Tennis Ball into the back of your PJ’s.
So every time you try to sleep on your back, your reduced
comfort level will encourage you to role to your side
.
Sleep Disorders Dentistry…
16. Surgery: most common are
Palatal Surgeries or variations
there of…
Sleep Disorders Dentistry…
17. Uvulopalatopharyngoplasty
(UPPP or UP3)
• UPPP involves the removal of the tonsils,
followed by removal of the anterior surface of
the soft palate and uvula, folding of the uvula
toward the soft palate and suturing it together
as demonstrated in the figures. In the US,
UPPP is the most commonly performed
procedure for obstructive sleep apnea, with
approximately 33,000 procedures per year. The
surgery is more successful in patients who are
not obese, and there is a limited role in
morbidly obese (>40 kg/m2).
• Success; 25-50% for OSA, 75% for Snoring
Sleep Disorders Dentistry…
19. nCPAP: Pumps air into nose under pressure to expand collapsed airway
Overall, 65% compliance after 6 months
Average 3-4 nights a week, 3-4 hours a night
Compliance lower if <30 events per hour (Mild to Moderate Sleep Apnea)
Almost %100 Effective in Eliminating Apnea
BUT: when compliance is considered “Adjusted nCPAP effectiveness” is 50%
Eur Respir J 2000;16(5):921-7
.
.
Sleep Disorders Dentistry…
22. Mandibular Advancement
Devices
Most Effective Airway Orthotics
Some Examples…
Sleep Disorders Dentistry…
Dorsal
Herbst
EMA
Example of Orthotic in Mouth
SUAD
Narval
Example of Orthotic in Hand
Tap
Silencer
24. Airway Without Airway Orthotic Airway With Airway Orthotic
Airway Orthotic increases Airway SizeAirway Orthotic increases Airway Size
Making the Airway Less CollapsibleMaking the Airway Less Collapsible
See MRI Images Below Showing Increase in Airway SizeSee MRI Images Below Showing Increase in Airway Size
.
Increase Occurs with Mandibular AdvancementIncrease Occurs with Mandibular Advancement
Sleep Disorders Dentistry…
25. SIDE EFFECTS:
Mostly Short lived and Upfront
Mostly due to resisting the new jaw position during sleep
Once jaw resistance stops – the discomforts stop
Excessive Salivation lasts for approximately 2 Weeks
Long Term Wear is Associated with Bite Changes
This same side effect occurs with long term nCPAP wear
No permanent cases of TMJ have been reported
Sleep Disorders Dentistry…
26. Airway Orthotics… the Facts…
Airway Orthotics are considered First Line Therapy for the
management of Snoring, Mild & Moderate Sleep Apnea. Sleep 2006:29:2
256 patient study – 90% patient compliance after 2 ½ years of wear.
CRANIO 2000:18:2
Ten out of eleven prefer an Airway Orthotic over nCPAP for their
long term treatment. Thorax 1997, 52:362-368
Sleep Disorders Dentistry…
Know the Facts Before You Decide Which Therapy is For You
27. The Dentist, Physician and Sleep Specialist workThe Dentist, Physician and Sleep Specialist work
together in the treatment of Snoring and Sleep apnea.together in the treatment of Snoring and Sleep apnea.
Communication is Key to Optimum TreatmentCommunication is Key to Optimum Treatment.
Sleep Disorders Dentistry…
28. Thank You & Sweet Dreams
snoresolutions@aol.comsnoresolutions@aol.com
SleepDisordersDentistry.comSleepDisordersDentistry.com