Vol.

23, Number 12 December 2001

Obstructive sleep apnea
Lieutenant Commander Donald A. Lonergan, DC, USN and Captain Scott A. Synnott, DC, USN
b!tructi"e Sleep Apnea #SA$ i! a clinical !ubtype
o% Upper Air&ay Sleep Di!order! #UASD$. Sleep
apnea i! a !eriou! and potentially li%e t'reatening
di!order. Clinical %eature! o% t'e di!order include
e(ce!!i"e daytime !leepine!!, in!omnia, 'eadac'e!,
!noring, abnormal motor acti"ity during !leep,
intellect and per!onality c'ange!, 'yperten!ion, cor
pulmonale, 'eart %ailure, and polycyt'emia. Snoring i!
t'e mild %orm o% UASD) SA i! t'e !e"ere %orm.
According to t'e National Commi!!ion on Sleep
Di!order! re!earc' report, it 'a! been e!timated t'at
!noring a%%ect! up to 2*+ o% male!, SA occur! in
appro(imately 2,-+ o% t'e American population #1$.
UASD.! are generally t'e re!ult o% a condition t'at
cau!e! partial or complete ob!truction o% t'e air&ay
&'en t'e patient a!!ume! a !upine po!ition and goe!
to !leep. /reatment o% UASD i! a multidi!ciplinary
team approac'. 0ncrea!ed number! o% patient! are
no& being re%erred to denti!t! %or treatment u!ing
remo"able oral de"ice!. /'i! clinical update pre!ent!
an o"er"ie& o% t'e anatomical, diagno!tic and current
treatment a!pect! o% SA.
Anatomy
0n t'e normal anatomy, t'e acti"itie! o% t'e ten!or
"eli palatini, le"ator "eli palatini, genioglo!!u!, and
genio'yoid mu!cle! maintain t'e po!ition o% t'e
tongue, !o%t palate, u"ula, and 'yoid bone in a
po!ition a&ay %rom t'e po!terior &all o% t'e p'aryn(.
/'e acti"ity o% t'e!e mu!cle! dimini!'e! greatly
during rapid eye mo"ement #123$ !leep. /'e air&ay
o% !noring patient! remain! patent but partially
ob!tructed. /'e ob!truction re!ult! %rom t'e tongue
or 'yoid bone dropping bac4 to t'e po!terior
p'aryngeal &all &'en t'e patient !leep! in a !upine
po!ition. /'e e%%ort! to get !u%%icient o(ygen to t'e
lung! cau!e an increa!ed "elocity o% air pa!!ing
t'roug' t'e reduced air&ay !pace. /'i! o%ten cau!e!
t'e !o%t palate and5or u"ula to "ibrate. /'e "ibration
i! t'e !ound o% !noring #2$.
SA patient! 'a"e an almo!t completely or
completely ob!tructed upper air&ay. /'e!e patient!
can !u%%er %rom 'undred! o% apneic e"ent! per nig't.
Apneic e"ent! are by de%inition bloc4age! o% t'e
air&ay la!ting more t'an 10 !econd! #1$ re!ulting in
multiple arou!al!, cau!ing lo!! o% bot' 6uality and
6uantity o% !leep. 7o!terior po!itioning o% t'e tongue
and 'yoid) in%lammation o% t'e ton!il!, adenoid!,
epiglotti!) tumor!) obe!ity) and !tructural compromi!e
may cau!e ob!truction. /'e u!e o% !edati"e! and
et'anol 'a! al!o been a!!ociated &it' e(acerbation o%
UASD #1$.
Diagnosis
/'e denti!t !'ould be re!pon!ible %or recogni8ing
potential upper air&ay !leep di!order patient!.
UASD!, and SA in particular, are medical problem!
t'at are potentially li%e t'reatening. /'e!e patient!
!'ould be re%erred to a p'y!ician %or diagno!i! and
treatment. /'e denti!t !'ould !upport t'e p'y!ician in
t'e treatment p'a!e &'en re6ue!ted by proper
re%erral. /'e denti!t mu!t not a!!ume t'e role o%
primary care pro"ider %or any UASD5SA patient #3$.
Diagnostic tests
Serum laboratory te!t! on !u!pected SA patient!
during &a4ing 'our! are &it'in normal limit!. 7atient
or !pou!e report! are !ub9ecti"e. /'e de%initi"e
diagno!tic te!t %or !leep apnea patient! i! t'e all,nig't
poly!omnogram. /'e poly!omnogram mea!ure!
o(ygen !aturation le"el!, number and lengt' o% apneic
epi!ode!, !leep !tage!, air%lo&, re!piratory e%%ort and
'eart rate. /'i! te!t allo&! t'e calculation o% t'e
1e!piratory Di!turbance 0nde( #1D0$ &'ic' indicate!
t'e apneic e"ent! per 'our. An 1D0 o% greater t'an *
i! abnormal, *,20 i! mild, 20,*0 i! moderate and
greater t'an *0 indicate! a !e"ere SA patient #2$.
Treatment
nce a diagno!i! o% SA i! made, t'e p'y!ician
'a! %i"e treatment option!: be'a"ioral modi%ication,
!urgery, continuou! po!iti"e air pre!!ure #C7A7$, oral
de"ice! and medication. 3edication! 'a"e been
pro"en to be o% minimal bene%it and are not o%ten
Clinical Update
Naval Postgraduate Dental School
National Naval Dental Center
Bethesda, Maryland
22
u!ed. ;e'a"ior modi%ication! include &eig't lo!!,
c'ange o% !leep po!ition, and reducing t'e inta4e o%
alco'ol or !edati"e!. /'e!e modi%ication! 'a"e not
been !'o&n to 'a"e long,term !ucce!!) 'o&e"er,
patient! are !ometime! !ucce!!%ully treated u!ing
t'e!e !imple procedure! and t'ey !'ould not be
o"erloo4ed.
Surgery i! o%ten in t'e %orm o%
u"ulopalatop'aryngopla!ty #U777$, la!er,a!!i!ted
U777 #LAU7$, ton!illectomy, adenoidectomy,
trac'eotomy, mandibular ad"ancement, or 'yoid bone
li%t. U777 i! !ucce!!%ul in **+ o% t'e SA patient!
and LAU7 i! no& indicated primarily in !noring
patient!. /on!il and adenoid !urgery i! o%ten o%
bene%it in c'ildren. ;ecau!e o% e!t'etic and !ocial
compromi!e!, trac'eotomy i! re!er"ed %or li%e,
t'reatening !ituation!. 3andibular ad"ancement and
'yoid bone procedure! 'a"e been !'o&n to be
!ucce!!%ul in treating SA and !noring.
C7A7 i! con!idered t'e gold !tandard %or treating
moderate to !e"ere SA patient! but i! con!idered
e(ce!!i"e %or !noring patient!. C7A7 i! a treatment
modality t'at utili8e! a pump %orcing room air t'roug'
t'e patient.! na!al ca"ity and upper air&ay. 0t !u%%er!
%rom poor compliance due to lac4 o% portability,
noi!e, di!com%ort o% &earing a ma!4 and limitation o%
patient mo"ement.
Oral Devices
/'e patient i! o%ten re%erred to a denti!t %or
treatment &it' an oral de"ice. /'ere are t&o type! o%
oral appliance! %or treatment o% SA, t'e /ongue
1etaining De"ice #/1D$ and t'e 3andibular
Ad"ancement De"ice #3AD$. /'e /1D! &or4
t'roug' t'e u!e o% a 'ollo& bulb and !u%%icient
"acuum to 'old t'e tongue %or&ard. /'e 3AD!
&or4 indirectly by 'olding t'e mandible and t'ere%ore
t'e tongue %or&ard. /'e!e de"ice! al!o aid in
pre"enting t'e 'yoid bone %rom dropping po!teriorly
and it! o"erlying ti!!ue! %rom impinging on t'e upper
air&ay #-$.
ral de"ice! and U777 'a"e !imilar !ucce!! rate!
treating SA, and oral de"ice! are al!o !ucce!!%ul in
appro(imately *0+ o% !urgical #U777$ %ailure
patient!. 7atient compliance &it' oral de"ice! i! o%ten
better t'an &it' C7A7. ral de"ice! are e(tremely
!ucce!!%ul in treating !noring,only patient! #1$.
3AD! may be !ingle po!ition !toc4 de"ice!,
ad9u!table !toc4 de"ice!, or cu!tom made in t'e
laboratory. /'e 3AD i! u!ually %abricated to 'old t'e
mandible %or&ard in a po!ition appro(imately <0+ o%
t'e patient.! ma(imum protru!i"e range and &it'
bet&een * to < mm o% oral opening #*$. /'e
ad9u!table model! are generally pre%abricated de"ice!
t'at allo& a range o% ad9u!tment in controlling t'e
protru!ion o% t'e mandible. An e(ample o% a
pre%abricated ad9u!table de"ice i! t'e /'eraSnore
#Di!tar, 0nc., Albu6uer6ue, N3$. Single po!ition
appliance! are %i(ed in a !elected po!ition. Stoc4
t'ermopla!tic de"ice! re6uire 'eating and intraoral
adaptation to re!train t'e mandible in t'e !elected
po!ition.
=or %abrication o% t'e laboratory proce!!ed 3AD!,
ca!t! o% t'e ma(illary and mandibular teet' are
articulated at t'e !elected protru!i"e and increa!ed
"ertical dimen!ion o% occlu!ion. Determination o% t'e
proper protru!i"e po!ition i! made c'air!ide. /'e
patient.! range o% protru!i"e motion i! mea!ured. /'i!
proce!! i! !impli%ied &it' t'e u!e o% a >eorge >auge
#>reat La4e! rt'odontic!, /ono&anda, N?$, &'ic'
'a! a !cale to mea!ure t'e patient.! protru!i"e motion
and !et!cre&! to 'old t'e mandible at a gi"en
po!ition. @it' t'e gauge at t'i! po!ition, a ma(illo,
mandibular recording medium i! u!ed on t'e bite %or4
o% t'e gauge to record t'e amount o% opening and t'e
protru!i"e po!ition de!ired.
Succe!! rate! are !imilar &it' eit'er pre%abricated
or lab proce!!ed appliance!. Complication!
a!!ociated &it' t'e!e oral de"ice! are generally minor,
con!i!ting primarily o% tran!ient occlu!al c'ange! and
mu!cular di!com%ort.
References:
1. 0"an'oe A1. 0n: /aylor /D, editor. Clinical 3a(illo%acial
7ro!t'etic!. C'icago: Buinte!!ence 7ubli!'ing, 0nc.) 2000. p.
21*,231.
2. 3eyer A; and Cnud!on 1C. /'e !leep apnea !yndrome.
7art 0: Diagno!i!. A 7ro!t'et Dent 1DED Dec)F2#F$:F<*,D.
3. 7ractice 7arameter! %or t'e /reatment o% Snoring and
b!tructi"e Sleep Apnea &it' ral Appliance!. Sleep 1DD*
Aul)1E#F$:*11,3.
-. Cnud!on 1C, 3eyer A; and 3ontal"o 1. Sleep apnea
pro!t'e!i! %or dentate patient!. A 7ro!t'et Dent 1DD2
Aul)FE#1$:10D,11.
*. L.2!trange 71, ;attagel A3, Gar4ne!! ;, Spratley 3G,
Nolan 7A and Aorgen!en >0. A 3et'od o% !tudying adapti"e
c'ange! o% t'e orop'aryn( to "ariation in mandibular po!ition
in patient! &it' ob!tructi"e !leep apnoea. A ral 1e'abil 1DDF
ct)23#10$:FDD,<11.
Lieutenant Commander Lonergan i! a re!ident in t'e 7ro!t'odontic!
Department. Captain Synnott i! t'e C'airman o% t'e 7ro!t'odontic!
Department at t'e Na"al 7o!tgraduate Dental Sc'ool.
/'e mention o% any brand name! in t'i! Clinical Update doe! not
imply recommendation or endor!ement by t'e Department o% t'e
Na"y, Department o% De%en!e, or t'e US >o"ernment.
/'e opinion! or a!!ertion! contained in t'i! article are t'e pri"ate one!
o% t'e aut'or! and are not to be con!trued a! o%%icial or re%lecting t'e
"ie&! o% t'e Department o% t'e Na"y.
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