Sleep disorders dentistry

What is…
Sleep Disorders Dentistry
John Viviano BSc DDS D ABDSM

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

Yearly Cost to Society (USA): Approaching $200 Billion

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

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
.

Why me…
Narrowing of the upper air-passages
Reduced airway muscle tone
Nasal obstruction
Obesity
Drugs
Alcohol
Fatigue
Smoking
Heredity

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

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)

 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
.

Epworth Sleepiness Scale
Score over 10 suggests a Sleep Disorder

 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
.

 Literature Validated Therapies AASM Sleep 2006
 Lifestyle Choices
 Positional Therapy
 Surgery
 nCpap
 Airway Orthotics
.

 Lifestyle Choices…
 Reduce Weight
 Increase Physical Fitness
 Avoid Alcohol & CNS Depressant Medications
 Avoid Smoking
.

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
.

Surgery: most common are
Palatal Surgeries or variations
there of…

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

Laser Assisted
Uvulopalatoplasty (LAUP)
◦Success; Not for Apnea, 50% for Snoring
◦Relapse a problem, Apnea may Worsen

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
.
.

nCPAP Prescribed Most Often

The
Airway
Orthotic
Solution

Mandibular Advancement
Devices
Most Effective Airway Orthotics
Some Examples…
Dorsal
Herbst
EMA
Example of Orthotic in Mouth
SUAD
Narval
Example of Orthotic in Hand
Tap
Silencer

Airway Blockage Without Orthotic
Airway Splinted Open With Orthotic

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

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

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
Know the Facts Before You Decide Which Therapy is For You

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.

Thank You & Sweet Dreams
snoresolutions@aol.comsnoresolutions@aol.com
SleepDisordersDentistry.comSleepDisordersDentistry.com

Sleep disorders dentistry

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