Sleep Disordered Breathing
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1 Obstructive Sleep Apnea: The Case for Oral Appliances by Alan A. Lowe DMD, PhD, FRCD(C) AAO Winter Conference February 7, 2014 UBC Dentistry Sleep Apnea Team Alan A. Lowe Professor Fernanda Almeida Assistant Professor Ben Pliska Assistant Professor Hui Chen Clinical Assistant Professor Mary Wong Programmer/Data Base Manager Sandra Harrison Clinical Trials Coordinator Sleep Disordered Breathing Snoring Upper Airway Obstructive Resistance Sleep Apnea Syndrome Mild Mild Mild Moderate Moderate Moderate Severe Severe Severe +/- Symptoms ++/- Symptoms ++++/- Symptoms +/-Health Implications ++/-Health Implications +++++Health Implications Oral Appliances AASM Practice Parameters (Sleep, 2006; 29: ) Diagnostic evaluation required at baseline for all patients OA to be fitted by a dentist Indicated for snorers after no behavioral change Indicated for mild and moderate OSA Initial trial of CPAP before OA in severe OSA Follow-up PSG for OSA patients required Regular medical/dental visits to assess for worsening OSA OA Patient Titration Goals The patient feels more rested during the day and experiences deep uninterrupted sleep. A resolution of morning headaches has occurred. An inability to tolerate any further advancement. A change in dream patterns may indicate REM catch up. A history from the bed partner (bed side tape recorder) that the snoring intensity and/or frequency has changed. Usually a Snore Score of 2 or 3 suggests that the airway is open. However, be cautious of silent apneics until after the follow up analysis is completed. Titration Aids Patient or bed partner titration goals Oximetry at home Portable monitoring at home Polysomnogram attended in the laboratory 1
2 Effects on Airway Size Before Insertion After Insertion Before Insertion After Insertion Before Insertion After Insertion To computer Magnet sensor Magnet 2
3 VERTICAL MANDIBULAR POSTURE BEFORE DURING AND AFTER APNEIC EVENTS During NREM Opening was larger in latter half of apneic event than before and at onset Opening progressively increased during apneic event Opening decreased at end of apneic event During REM No significant change Oral appliances may be effective since they stabilize mandibular posture during apneic events TIME IN EACH RANGE DURING NREM AND REM FOR OSA PATIENTS AND CONTROLS During NREM Open 2 to 2.5 less in OSA Open 5 to 10 and more greater in OSA During REM Open 0 to 2.5 less in OSA % total time open more than 5 is larger in OSA patients (69.3) than in controls (11.1) during NREM sleep Criteria Mild Moderate Subjective 36% 20% Clinical 82% 50% RJM 54% 40% Bruxism (2 of 3) 55% 40% Overall 48% Control 8% OA and Sleep Bruxism An adjustable OA reduced episodes + number of bursts/hr and SB episodes with tooth-grinding noises 25% protrusion reduced SB events by 39% 75% protrusion reduced SB events by 47% An OA may be an alternative for SB and snoring/osa patients Landy-Schonbeck et al, Int J Prosthodont 2009; 22: L24 Snoring and Occlusal Splints Maxillary occlusal splint worn for 7 nights in subjects with snoring and OSA AHI increased 50% in half of the patients Snoring time increased by 40% Significant risk of aggravation of respiratory disturbances Potential reduction of intraoral and tongue space as well as an increase in the vertical dimension Gagnon et al, Int J Posthodont 2004;17: Occlusal Changes After Five Years of OA Use No Change Favorable Change Unfavorable Change Correction of Class ll molar Edge to edge incisors Correction of Class ll cuspid Reverse OJ or OB Reduced OJ or OB Vertical open bite Reduced palatal impingement Reduced interarch contacts Reduced lower incisor crowding Posterior cross bite 3
4 70 OSA Patients No Change 10 (14.3%) Change Favorable 29 (41.4%) Small 13 Intermediate 13 Large 3 Skeletal Type and Outcomes 60 (85.7%) Unfavorable 31 (44.3%) Small 8 Intermediate 15 Large 8 Class I Class II/1 Class II/2 Class III No Change 12.5% 10% 20% 50% Favorable 25.0% 90% 80% - Unfavorable 62.5% % Duration of OA Wear and Amount of Change Craniofacial Appliance Design Changes < 6yrs 6-8yrs >8yrs SNAº SNPGº SNMPº TFH OB MDMH U6S LU6SN Case 5 Appliance Design Changes How long was an OA used in this next patient? Case 6 4
5 Four Years of Profile Lite Nasal Mask (Respironics) Hypothesis Long-term use of a ncpap machine could directly affect the maxilla as well as anterior tooth position. Aim To determine the prevalence and characteristics of dental and skeletal changes in long-term ncpap users and to estimate the factors that affect such changes. 5
6 SNU1 SNA SNB Superimposition on the SN line of a typical OSA subject at baseline and after 35M of ncpcp wear ANB SNPg Convexity baseline. follow-up Profile Lite Nasal Mask- Respironics NASAL PILLOW ALTERNATIVES Mirage Swift - ResMed Breeze SleepGear Puritan Bennett Date Questionnaire Min O2 (%) RDI/hr AHI/hr ODI/hr Pretreatment 2008/2/ Posttreatment (with Klearway) 2008/9/ Posttreatment (without Klearway) 2008/9/ Portable Monitor (Watch-Pat) How do Klearway and Twin Block functional appliances compare when used in young children with retruded mandibles? P value (baseline vs. followup) KW group TB group SNA SNB * *** ANB *** 0.020* Wits appraisal *** L1 protrusion (L1-Apo) *** *** L1-OP * 0.14 IMPA *** * Overjet *** *** Overbite * * * P<0.05 ** p<0.01 *** p<
7 Klearway Protocol consistent Rarely lost Compliance higher since only sleep time wear Keeps both jaws closed while sleep Less chair side adjustment No transverse expansion adjustments Retention less compromised in the mixed dentition Twin block Protocol various (combined with FEA, HG, etc) Higher chance to be lost Compliance lower due to full time wear No orthopedic effect during sleep if mouth breathing Longer appointment if adjustment needed Can adjust to allow transverse expansion Retention can be compromised in the mixed dentition Female DOB: Oct13/2002 Insertion date: Oct28/2011 Female DOB: Oct13/2002 Follow-up : Apr18/2012 Duration: 6 months (Phase I not finished) Female DOB: May18/2001 Insertion: Nov 4/2011 Female DOB: Oct13/2002 Follow-up : Mar2/2012 Duration: 4 months (Phase I finished) 7
8 Some OSA Guidelines for Orthodontists Don t hesitate to refer to adult/pediatric sleep specialists Avoid treatment without a written referral from a physician Be cautious in patients with previous orthodontic therapy Use recognized appliances with RCT research Both case and appliance selection are very important Be aware of silent apneics and post titration follow up Don t overtreat post OA or ncpap occlusal changes Not all Class IIs have OSA /not all OSAs are Class II Stay engaged in this rapidly changing and exciting field American Academy of Dental Sleep Medicine 2510 N Frontage Road, Darien, Illinois Phone: (630) Fax: (630) Web Site: The Web site has information about the AADSM, a geographic listing of members, certification status and Web site links. ACKNOWLEDGEMENT Klearway TM was invented by the presenter at The University of British Columbia. International patents have been obtained by the University and specific licensees are assigned the rights to manufacture and distribute the appliance world wide. IN CANADA Space Maintainers Laboratories Canada Ltd Vancouver Calgary Ottawa Toronto IN THE USA AND WORLDWIDE Great Lakes Orthodontics Ltd Tonawanda, NY Alan A. Lowe, DMD, PhD, FRCD(C) Professor and Chair, Division of Orthodontics Department of Oral Health Sciences Faculty of Dentistry, The University of British Columbia 2199 Wesbrook Mall, Vancouver, B.C. V6T 1Z3 Phone: (604) Fax: (604) alowe@interchange.ubc.ca 8
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