Obstructive Sleep Apnea : Role Of A Dental Surgeon
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All About Sleep

Sleep is defined as a period of rest for the body and mind during which consciousness are in partial or complete abeyance and the bodily functions are partially suspended. An average human being requires 8 hours of sleep (range:4 to 10 hours).

There are two main types of sleep:

  • Non Rapid Eye Movement (NREM):It is also known as quiet sleep
  • Rapid Eye Movement:It is also known as active sleep or paradoxical sleep.

Various Stages in Sleep Cycle:

The various stages of sleep are as follows:

— NREM STAGE 1: Stage 1 is the beginning of sleep cycle and is relatively a light stage of sleep. Stage 1 can be considered as a transition period between wakefulness and sleep. This period of sleep lasts only for a small time (around 5 to 10 minutes). If you wake up someone during this stage, they might report that they were not really asleep.

–NREM STAGE 2: Stage 2 is the second stage of sleep and lasts for approximately 20 minutes. During stage 2, you become less aware of your surroundings, body temperature drops, breathing and heart rate become more regular. People spend 50% of their total sleep in this stage.

–NREM STAGE 3: During stage 3 sleep:

  1. Muscles relax
  2. Blood pressure & breathing rate drops
  3. Deepest sleep occurs in this stage
  4. Bedwetting & sleep walking occurs during this stage.

–REM SLEEP: It is the stage 4 of sleep. Following happens in this stage:

  1. The brain becomes more active.
  2. The body becomes relaxed & immobilized.
  3. Dreams starts occuring.
  4. Eyes move rapidly. People spend 20% of their total sleep in this stage.

Sequence of Sleep:

Sleep begins with stage 1 and progresses to stage 2 & stage 3. After stage 3, stage 2 sleep is repeated before entering REM sleep. Once REM sleep is over, the body returns to stage 2. Sleep cycles through these stages approximately four or five times throughout the night. On an average, we enter REM sleep approximately 90 minutes after falling asleep. The first cycle of REM sleep lasts only for few minutes, but each cycle becomes longer. REM sleep can lasts upto an hour.

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All About Sleep Apnea

OBSTRUCTIVE SLEEP APNEA (OSA): Obstructive Sleep Apnea (OSA) is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the common type of Sleep Disordered Breathing (SDB) and is characterized by recurrent episodes of upper airway collapse during sleep.

UPPER AIRWAY RESISTANCE SYNDROME (UARS):Upper Airway Resistance Syndrome (UARS) is caused by slowing or blocking of air in the nasal passages during sleep, disrupting it & causes fatigue.

Definitions Of Respiratory Events:

— APNEA: Apnea is defined by the American Acadey Of Sleep Medicine (AASM) as the cessation of airflow for atleast 10 seconds.

–HYPOPNEA: Hypopnea is defined as recognizable transient reduction (but not complete cessation) of airflow for 10 seconds or longer.

Pathophysiology Of Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea (OSA) is caused by soft tissue collapse in the pharynx. Transmural pressure is the difference between intra-luminal pressure & surrounding tissue pressure. If transmural pressure decreases, the cross sectional area of the pharynx decreases too. If this pressure passes a critical point, pharyngeal closing pressure is reached. Exceeding pharyngeal critical pressure causes tissue collapsing inward and the airway gets obstructed.

Different Types Of Sleep Apnea:

— OBSTRUCTIVE: The airway becomes narrowed, blocked or floppy in this type of apnea.

–CENTRAL: There is no blockage of the airway, but the brain doesn't signal the respiratory muscles to breathe.

–MIXED: Combination of obstructive & central sleep apnea.

Etiology Of Obstructive Sleep Apnea:

1) ANATOMIC FACTORS: — Enlarged tonsils.

  • Volume of the tongue.
  • Soft tissue.
  • Length of soft palate.
  • Abnormal positioning of the maxilla & mandible.

2) STRUCTURAL FACTORS: — Retrognathia & Micrognathia due to

  • Mandibular hypoplasia.
  • Brachycephalic head form.
  • Pierre Robin Syndrome.
  • Down Syndrome.
  • Marfan Syndrome.
  • High arched palate.
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##Nasal Obstruction: Polyps, Septal deviation, Tumors ,Trauma and Stenosis.

##Retropalatal Obstruction: Elongated, posteriorly placed uvula ,tonsil and adenoid hypertrophy.

##Retroglossal Obstruction: Macroglossia & tumor

3) NON STRUCTURAL RISK FACTORS

  • Obesity.
  • Sedative state.
  • Alcohol use.
  • Supine sleep position.
  • Hyperthyroidism.
  • Acromegaly.

Symptoms Of Obstructive Sleep Apnea

The symptoms include the the following:

  • Snoring , which other people in different rooms can hear even when doors & windows are closed.
  • Insomnia.
  • Nocturia.
  • Restless sleep.
  • Non restorative sleep.
  • Waking up as tired in the morning.
  • Hypertension.
  • Morning confusion.
  • Depression.
  • Fatigue & tired during the daytime.

Diagnosis of Obstructive Sleep Apnea

Obstructive Sleep Apnea is diagnosed through the following:

  • Polysomnogram
  • MRI
  • Fluoroscopy
  • CT
  • Cephalometry (MC Namara Analysis)

POLYSOMNOGRAM:

OSA is usually diagnosed by Polysomnogram. It usually requires that the patient stay overnight in a hospital or a sleep medicine study center.

Polysomnogram measures the activity of different organ systems associated with sleep.

It may include:

Electroencephalogram: It measures the activity of brain

Electrooculogram: It measures the activity of eyes.

Electromyogram: It measures the activity of muscles.

Electrocardiogram: It measures the activity of heart.

Pulse oximeter test: It measures the oxygen saturation level in the body.

Arterial blood gas analysis: It measures the amount of arterial gases such as oxygen & carbon dioxide.

DIAGNOSTIC CRITERIA OF OBSTRUCTIVE SLEEP APNEA (OSA)

Individual must fulfill criterion A or B plus criterion C to be diagnosed with OSA.

Criterion A: Excessive daytime sleepiness that is not explained by other factors.

Criterion B: Two or more of the following that are not explained by other factors:

  • Choking or gasping during sleep.
  • Recurrent awakening from sleep.
  • Unrefreshing sleep.
  • Daytime fatigue.
  • Impaired concentration.

Criterion C: Overnight monitoring demonstrates 5 to 10 or more obstructed breathing events per hour during sleep or greater than 30 events per 6 hours of sleep.

Treatment Of Obstructive Sleep Apnea

Treatment involves:

  1. Home remedies.
  2. Medications.
  3. Oro nasal devices or appliances.
  4. Surgical.

1) Home Remedies: Home remedies involves-

  • Lose weight if overweight.
  • Exercise regularly.
  • Quit Alcohol.
  • Quit Smoking.
  • Don't sleep on back.
  • Don't take sedative medicines such as anti-anxiety drugs or sleeping pills.
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2) Medications: It involves the following-

  • Paroxetine: It's daily dose is 20 mg. It increases the activity of tongue muscle named ' genioglossus' for a given level of inspiration effort in NREM sleep.
  • Fluoxetine: It's daily dose is 20 mg. It decreases the number of episodes of apnea or hypopnea during NREM sleep.
  • Modafinil: It's daily dose is 200-400 mg. It reduces extreme sleepiness & periods of stopped breathing.
  • Armodafinil: It's functions is same as that of Modafinil and it's daily dose is 150-250 mg.
  • Nasal decongestants: Oxymetazoline, phenylephrine & psedudoephedrine are prescribed.

3) Oro-Nasal devices or appliances:

  • Anti snore nasal devices such as snorex can be used by the patient.
  • Tongue retainers are used.
  • Mandibular advancement devices are used to hold the maxilla & mandible in most protrusive position to prevent OSA.
  • Herbst appliances may also be used in treating OSA.

Oral appliances are indicated in primary snoring, mild or moderate obstructive sleep apnea.

Severe obstructive sleep apnea is treated by nasal Continuous Positive Airway Pressure (CPAP) & Bilevel Positive Airway Pressure (BPAP).

4) Surgical Treatment:

The surgical treatment of OSA involves:

  • Adenoidectomy
  • Polypectomy
  • Septoplasty
  • Uvulopalatopharyngoplasty
  • Reduction glossectomy etc.

Dr Mriganka Sekhar Ghose
Dr Mriganka Sekhar Ghose [BDS, Paed Dent Spclty Prog (Royal College Of Surgeons, Ireland] is a dental surgeon & independent medical researcher with multiple certifications from RCS Edinburgh, Ireland & Tehran Univ Of Medical Sciences, Iran and is Community Ambassador of Mohammad Rashid Bin Univ of Medicine & Health Sciences, UAE.

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