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: At the beginning of the sleep cycle, Stage 1 is a light stage of sleep that could be regarded as a transition phase between wakefulness and sleep. This phase lasts for a brief period of around 5 to 10 minutes, and if someone were awakened during this stage, they might report that they were not really asleep.

NREM STAGE 2: The second stage of sleep is referred to as Stage 2 and persists for roughly 20 minutes. In this stage, you become less conscious of your surroundings, your body temperature drops, and your breathing and heart rate become more regular. People typically spend half of their total sleep in this stage.

NREM STAGE 3: During Stage 3 sleep:

  • Muscles relax
  • Blood pressure and breathing rate drop
  • The deepest sleep occurs in this stage
  • Bedwetting and sleepwalking can occur in this stage

REM SLEEP: Also known as Stage 4, during this stage:

  • Brain activity increases
  • The body becomes relaxed and immobilized
  • Dreams occur
  • Eyes move rapidly

People generally spend nearly 20% of their entire 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.
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2) STRUCTURAL FACTORS: — Retrognathia & Micrognathia due to

  • Mandibular hypoplasia.
  • Brachycephalic head form.
  • Pierre Robin Syndrome.
  • Down Syndrome.
  • Marfan Syndrome.
  • High arched palate.

##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)

In order to be diagnosed with obstructive sleep apnea (OSA), an individual must fulfill either criterion A or B, in addition to criterion C.

Criterion A involves experiencing excessive daytime sleepiness that cannot be attributed to any other factors.

Criterion B requires two or more of the following symptoms that cannot be explained by any other factors:

  • Choking or gasping during sleep
  • Recurrent awakening from sleep
  • Unrefreshing sleep
  • Daytime fatigue
  • Impaired concentration
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Criterion C necessitates overnight monitoring that shows 5 to 10 or more instances of obstructed breathing per hour during sleep, or over 30 events within a 6-hour period 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.

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.

Reference:
https://emedicine.medscape.com/article/295807-overview

Author

  • Dr Mriganka Sekhar Ghose

    Dr Mriganka Sekhar Ghose is a dental surgeon, a medical researcher, a medical inventor and a medical author. He has done many certificate trainings from the Royal Colleges Of Surgeons of England & Edinburgh.

Dr Mriganka Sekhar Ghose is a dental surgeon, a medical researcher, a medical inventor and a medical author. He has done many certificate trainings from the Royal Colleges Of Surgeons of England & Edinburgh.

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