Obstructive Sleep Apnea
Health depends on various factors, with breathing, eating, hydration, and sleep being a crucial variable among them. However, each patient is susceptible to changes caused by a large number of variables with different degrees of physical and mental consequences. Sleep-disordered breathing (SDB) is a relatively common problem, with obstructive sleep apnea (OSA) being its most severe manifestation.
OSA is a prevalent and commonly undetected health problem that involves repeated upper airway collapse during sleep, causing a reduction (hypopnea) or cessation (apnea) of airflow, oxygen desaturation, and fragmented sleep, accompanied by respiratory effort. Whilst snoring can be a presenting symptom, it may not occur in an isolated manner. The disease is usually diagnosed based on laboratory full-night polysomnography (PSG).
The pathophysiology of OSA during childhood is poorly known, although adenotonsillar hypertrophy and the installation of oral breathing are the major factors contributing to its occurrence. In general, studies report that the problem affects 1%–5% of the child population, with a peak of incidence among preschoolers, that is, in the age range when tonsil hypertrophy is more common. The consequences of OSA in children are low school performance, attention deficit and hyperactivity, low weight–height development and cardiovascular dysfunction.
During adulthood, anatomical and nonanatomical factors interact and contribute to the manifestation of OSA, such as narrow pharynx, increased upper airway length, specific pharyngeal shapes, and a collapsible upper airway. The factors that may play a role in OSA pathogenesis are changes in the activity of oropharyngeal muscles that may occur during sleep, a genioglossus muscle poorly responsiveness to negative pharyngeal pressure, a low respiratory arousal threshold, and an oversensitive ventilatory control system.
The disease is more common among men than women and its prevalence increases with age and in obese persons. However, menopause is a risk factor for women regardless of age or body mass index (BMI), a factor that tends to reduce the difference from men, especially when no hormone replacement therapy is used. The symptoms of OSA include loud snoring, sleep disruption, excessive daytime sleepiness, nocturia, fatigue, morning headache, irritability, decreased concentration, and memory loss.
OSA impairs the quality of life and is considered to be a progressive and incapacitating chronic disease and may result in comorbidities including arterial hypertension, cardiovascular diseases, and diabetes. However, the clinical manifestations are heterogeneous, and if the patients do not present characteristics such as a high BMI and subjective sleepiness, the symptoms may also be attributed to other accompanying diseases and OSA may not be investigated and diagnosed.
The first-line treatment during childhood is adenotonsillectomy, with reported cure or improvement of the disorder in most cases.Orthodontic treatment for correction of mandibular or maxillomandibular anomalies has been shown to improve OSA. Continuous positive airway pressure (CPAP) is the treatment of choice for adults with OSA, especially in severe cases, to relieve symptoms and to reduce the sequelae. However, mandibular advancement device (MAD), an intraoral dental splint used to protrude the mandible in a forward position during sleep and thus enlarge the upper airway, is mainly indicated as the first-stage treatment of adults with mild-to-moderate OSA and in severe cases in which attempts with CPAP treatment fail. MAD has even been considered as a treatment option for children, although it is still under study, and it requires accurate indication and follow-up due to the craniofacial growth and development.
Further, surgical interventions are recommended for the correction of anatomical and morphological problems or as a second option for adult patients who fail to adhere or respond to noninvasive treatments. Surgical procedures include uvulopalatopharyngoplasty, surgically assisted rapid maxillary expansion, and maxillomandibular advancement.
Despite success with these interventions in reducing apnea–hypopnea index (AHI) and symptoms related to OSA, the need for new or complementary therapeutic modalities for OSA has been pointed out. The main reasons for this are the percentage of patients who do not respond satisfactorily to available treatments, the reduced adherence to CPAP, especially when the severity of the disease is moderate, and the possible complications of surgical procedures, even when limited.
Orofacial myofunctional therapy (OMT), or oropharyngeal exercises, with one of the focal points in the promotion of changes in dysfunctional upper airway muscles, has been proposed with success for reducing OSA severity and associated symptoms in adults. Since then, the potential of OMT has also been investigated to promote reduction of snoring, improvement of quality of life, and adherence to the use of CPAP, as well to treat residual OSA in children.
At my clinic consultation visit
I will do a comprehensive assessment prior to developing a treatment plan that will suit your needs. A detailed past dental and medical history will need to be assessed. Co-existing health conditions relating to daytime tiredness and anxiety, depression or post-traumatic stress disorder will be explored. Coordination with other involved healthcare providers, such as respiratory physcians, ENT surgeons, and general medical practitioners, may be required. All of this information will form the basis for appropriate dental and sleep apnea treatment planning.
My multimodal treatment will include a consultation, xrays and a functional analysis of your teeth using T Scan. In addition I typically advise a screening sleep test. Based on these results, you may be sent for a further examination by a Respiratory Physician or ENT Surgeon. Once your suitability for the Mandibular Advancement Device (MAD) is confirmed, we will proceed to customise a device for your comfort.
Many patients with obstructive sleep apnea or even snoring may face constant suffering and are typically unwilling to seek professional care for their dental conditions because of lack of knowledge as to how their suffering can be alleviated. However this is truly where I can help.
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