Sleep Apnea (Obstructive)

Sleep Apnea (Obstuctive)

• Introduction

  Obstructive sleep apnea (OSA) is a common condition and the most prevalent form of sleep apnea, accounting for over 80% of sleep-related breathing disorders diagnosed in the United States.¹ During sleep, individuals with OSA experience intermittent breathing cessations (apneas) or partial obstructions of the upper airway (hypopneas) with diminished airflow.^2-4

  The onset of sleep leads to decreased muscle tone and activity in the pharyngeal airway,⁵ which can result in airway narrowing or collapsibility that impairs normal ventilation.³ Individuals with anatomic or other risk factors (e.g., obesity, retrognathia, large tongue) may have increased risk of experiencing the often-cyclical respiratory events associated with OSA, as well as significant sleep fragmentation (due to repeated arousals from impaired breathing) and excessive daytime sleepiness.^{3, 4, 6}

  An obstructive apnea is a cessation or near cessation (≥90%) of breathing despite respiratory effort that lasts at least 10 seconds during sleep.⁷ Apneas usually last between 10-30 seconds, although some may extend to 60 seconds or more. Obstructive respiratory events commonly terminate with a cortical arousal or microarousal to restore breathing,⁸ along with neural activation of upper airway muscles to maintain patency.^{4, 6} Each night, patients with severe OSA may experience hundreds of apneas, hypopneas or respiratory effort-related arousals.

  Some individuals at high risk for OSA may present to clinicians without any clear, identifiable symptoms.⁹ Simple snoring (noisy breathing during sleep) is common but not always present in patients with OSA^{10, 11} since it does not involve full (or near) cessation of breathing (snorers may also have normal results in sleep studies).¹² Nevertheless, excessive daytime sleepiness and loud or irregular snoring are considered two hallmark symptoms of OSA,¹³ particularly when snoring is followed by breathing cessation (apnea) that may be accompanied by choking or gasping.¹⁰ Habitual or persistent snoring has been identified as a symptom suggestive of OSA in children.^{14, 15}

  A conventional overnight sleep test (polysomnography) with standard multi-channel recording has traditionally been considered the gold standard for comprehensive sleep evaluation and OSA diagnosis.³ Time-synchronized video recording is included during the overnight sleep study, plus sound recording to assess breathing and snoring levels. Home sleep apnea tests are also available to assist in measuring breathing patterns in uncomplicated adult patients who present with symptoms of sleep-related breathing disorders.³

  Obstructive sleep apnea is often undiagnosed and untreated,^16-20, but common signs and symptoms of OSA can be identified in various clinical settings, including dental practice. Dentists can work collaboratively with primary care physicians and sleep specialists, as part of a multidisciplinary care team, to assist in providing optimal long-term care of patients with OSA,²¹ with the ultimate goals of improving health and quality of life and reducing the incidence of OSA-related morbidity and mortality.

• Prevalence

  Prevalence estimates of OSA in patient populations are highly variable, depending on the definitions for OSA diagnosis and criteria for estimating its prevalence and severity.²² An epidemiologic review of studies over a 20-year period reported mean OSA prevalence levels of 22% for men and 17% for women.²³

  The prevalence of OSA tends to increase progressively with age.^{24, 25} In one study, OSA incidence increased from 3% of younger adults aged 20 to 44 years to 11.8% of middle-aged adults (aged 45 to 64 years) and over 23% of adults aged 65 years and older.²⁶ Overall, the prevalence of OSA in patients older than 65 years of age has been estimated to range between 13 and 32%.²⁷

  OSA is also more prevalent among men, particularly middle-aged men who exceed the minimum threshold for obesity (i.e., body-mass index [BMI] greater than or equal to 30).²⁸ Due to the increased morbidity and all-cause mortality associated with OSA,²⁹ the condition is a recognized public health issue.³⁰
  

• Symptoms, Risk Factors and Complications

  Common symptoms associated with OSA include one or more of the following: nocturnal choking or gasping,¹⁰ loud or irregular snoring,¹³ observed apneas during sleep (e.g., by spouse or bed partner),³¹ daytime sleepiness,³² nocturia,³³ dry mouth on awakening³⁴ and morning headache.³⁵

  There is certainly variability among individuals with OSA, and some may present without any complaints or identifiable symptoms.⁹ The pathogenesis of OSA is considered multifactorial,³⁶ and no single physical (anatomic) sign or symptom related to OSA can be viewed as a definitive indicator that the condition is present.³⁷ As an example, daytime sleepiness is a commonly reported symptom of OSA,^{32, 38} but it is not always present in individuals who are diagnosed with the condition.^{23, 39} Two systematic reviews concluded that another risk factor, alcohol consumption, can increase risk of developing OSA by 25%, and is associated with worsening OSA symptoms or complications.^{40, 41}

  Examples of risk factors associated with increased risk of OSA are summarized in Table 1.

  Table 1. Risk Factors Associated with Obstructive Sleep Apnea

  Overweight/obesity10, 42-46

  Retrognathia47/micrognathia48

  Large tongue49

  Male gender50, 51

  Enlarged neck circumference52

  Narrowing in regions of the upper airway (e.g., increased volume of lateral pharyngeal walls, tongue and total soft tissue)53

  Older age54

  Enlarged tonsils or adenoids (adenotonsillar hypertrophy)55, 56 [note: higher Mallampati airway classification is typically associated with increased risk of OSA]10, 57

  Nasal obstruction (e.g., chronic nasal inflammation, allergic rhinitis)36

  Alcohol consumption40, 41

  Family history of OSA58

  Ethnicity (e.g., African-American adults appear to have higher prevalence)59, 60

  
  Patients may be unaware of their own sleep-disordered breathing and the extent or severity of their repetitive (or transient) airway obstructions, arousals and awakenings during sleep. Patients may also be aware of their own snoring, daytime sleepiness or other OSA-related symptoms, but may not share that information with their physician or dentist.¹⁹

  Untreated OSA is characterized by recurrent collapse of the upper airway during sleep, resulting in cycles of breathing cessations and “micro-arousals” that induce oxidative stress, along with intermittent drops in blood oxygen saturation.⁶¹ Increasing levels of OSA severity are associated with greater systemic oxidative stress⁶² and increased risk of all-cause mortality.²⁹ The condition can also exert a significant impact on overall health, neurocognitive performance, personal relationships and routine daily functioning.^{63, 64} Examples of short- and long-term health complications associated with OSA are presented in Table 2.

  Table 2. Health Complications Associated with Obstructive Sleep Apnea

  Stroke and transient ischemic attacks65-67

  Cardiovascular disease67 (including fatal cardiovascular events)29, 68, 69

  Potentially increased cancer incidence and mortality6, 28, 29, 70-74

  Hypertension (present in nearly half of OSA cases)23

  Type 2 diabetes75

  Cognitive impairment76

  Dementia73, 77

  Depression51, 78 or mood and anxiety disorders79

  Sexual dysfunction73, 77

  Patients with OSA may report feelings of excessive daytime sleepiness or fatigue, two common symptoms of sleep fragmentation or poor sleep that are often directly attributable to OSA.⁸² Studies have shown that individuals with OSA have two to three times higher risk of experiencing a motor vehicle accident,^83-85 plus concomitant risks associated with drowsy driving.

  Sedation and Anesthesia: Patients with OSA should notify all health care providers, including dentists and surgeons, of their status and condition with regard to OSA (e.g., severity, extent of symptoms) to help ensure optimal patient safety during surgical procedures, including when conscious sedation or anesthesia is utilized.

• Diagnosis

  Diagnosis of OSA is made by a physician or trained sleep specialist after comprehensive assessment of the patient, including medical history, physical examination and diagnostic testing. Sleep-related considerations that may be addressed in a detailed health history include an assessment of sleep quality, history of snoring and awareness of gasping, choking, snorting or other breathing events. The health history-taking may also include any prior sleep-related diagnosis and use of (or recommendations for) PAP therapy. Other OSA-related symptoms during wake periods can also be evaluated, such as daytime sleepiness, fatigue or impaired concentration or focus during activities that require attentiveness (e.g., driving a vehicle).

  Dentists may supplement the patient’s comprehensive physical examination by providing a full examination of the oral cavity and the craniofacial region, including identification of structural abnormalities or physiologic indicators associated with OSA (e.g., large tongue or tonsils, retrusive jaw, large neck circumference).^{10, 86}

  The reference standard for OSA diagnosis is an overnight, attended sleep study (polysomnogram). This single-night study includes multichannel recordings of breathing patterns and airflow, duration of various stages of sleep, respiratory events (apneas and hypopneas), brain-wave activity, oximetry and cardiovascular function (e.g., electrocardiogram).^{87, 88}

  An in-lab sleep study quantifies obstructed breathing events using the apnea-hypopnea index (AHI), which presents an average measure of apneas and hypopneas recorded per hour of sleep. The AHI is commonly used for categorizing OSA severity. AHI scores of 5, 15 and 30 events per hour are the standard “cutoffs” for mild, moderate and severe OSA, respectively.⁷

  At-home sleep tests are also available and may provide a cost-effective option for some individuals. These portable home-monitoring devices generally track breathing patterns or disturbances during sleep rather than overall sleep quality. Clinical guidelines recommend that home sleep apnea tests only be used by uncomplicated adults who present with signs and symptoms that indicate an increased risk of moderate to severe OSA,³ and that they be used in conjunction with a comprehensive sleep evaluation.⁸⁹ Additionally, one clinical practice guideline on childhood obstructive sleep apnea advises clinicians to screen all children and adolescents for snoring.⁵⁵

  Clinical questionnaires⁹⁰ to assist with conducting OSA risk assessment are presented in Table 3.

  Table 3. Questionnaires for Obstructive Sleep Apnea Risk Assessment

  Name	Overview
  STOP-Bang Questionnaire	An eight-question checklist of symptoms associated with increased risk of OSA, which has been recommended as a screening tool with moderate-quality evidence.3 Positive answers to three of the eight questions identify individuals who meet the minimum threshold for intermediate OSA risk; five or more positive replies identify persons at severe risk.91
  Berlin Questionnaire	The Berlin questionnaire92 evaluates both daytime alertness and sleep variables (e.g., snoring, breathing disruptions during sleep), as well as other risk factors such as high body mass index and hypertension.
  Sleep Apnea Clinical Score (SACS)	A screening tool that assesses snoring, witnessed episodes of apnea, neck circumference and hypertension.
  Epworth Sleepiness Scale (ESS)	A subjective questionnaire that provides a general measure of an individual’s daytime sleepiness, a common symptom of sleep apnea.93 The ESS asks individuals to report how likely they are to fall asleep during eight different scenarios (e.g., watching television).
  Pittsburgh Sleep Quality Index	A self-report questionnaire that measures sleep disturbances and sleep habits over a one-month period.
  Snore Score™	A six-item quiz to help patients determine if they have symptoms related to obstructive sleep apnea.

  
  

• Treatment Options

  Physicians and sleep specialists serve as the primary health care providers in the diagnosis and management of OSA and other sleep-related breathing disorders. In the event oral appliances are the prescribed therapy, managing physicians may work with each patient’s dentist to ensure that a comprehensive oral clinical examination has been obtained when necessary, including intraoral and extraoral findings.

  Behavioral Options: As an initial treatment option, patients with mild-to-moderate OSA may begin with behavioral interventions or changes in lifestyle (diet, weight loss, exercise), particularly obese or overweight individuals with OSA or strongly suspected of having the condition.⁹⁴ Reducing alcohol consumption, especially before bedtime, may also provide therapeutic and preventive value.⁴⁰ Supplementary education can also be offered to advise patients of the negative impact on OSA therapy that may result from use of tobacco, alcohol or recreational drugs.

  Positional Sleep: Patients may also be advised that sleeping in a supine position (horizontal position with face and torso facing up) has been found to aggravate OSA-related symptoms.^{95, 96} This condition is known as position-dependent obstructive sleep apnea, and researchers estimate that up to half of all OSA-related cases in adults could be classified as supine-related OSA.⁹⁶

  For some adults, sleeping on one’s side (positional therapy) may assist in improving AHI levels and sleepiness measures (per the Epworth Sleepiness Scale).⁹⁷ For individuals with mild to moderate OSA, mild head-of-bed elevation may also assist in reducing OSA severity.⁹⁸ A patient’s primary care physician or sleep specialist may advise whether positional therapy might assist in providing therapeutic benefit and improved breathing stability.

  PAP Therapy: Positive airway pressure is recommended as a primary therapy for managing adult OSA.^{99, 100} PAP devices use air pressure from a mechanical device to counteract airway narrowing through the delivery of compressed air to the oropharynx. Air pressure is delivered through an air-tight attachment (e.g., a mask covering the sleeper’s nose), which splints  the airway with increased air pressure to maintain patency during sleep.¹⁰¹ PAP devices are available in a wide range of machine sizes and mask types. Based on the available evidence, PAP can provide patients with improved sleep patterns and quality of life when used consistently and properly.¹⁰¹

  Although PAP devices are commonly prescribed for the treatment of adult OSA, there are significant issues with patient compliance and adverse events (e.g., mask discomfort, oral dryness, nasal congestion).¹⁰² PAP therapy has a persistently low rate of adherence, ranging from 17% to 60% (with adherence defined as greater than four hours of use on 70% of nights).^103-105 The use of PAP also may not fully resolve an individual’s OSA or sufficiently reduce its severity.¹⁰¹ To improve patient comfort and adherence to PAP therapy, an American Academy of Sleep Medicine (AASM) guideline¹⁰⁰ recommends the use of heated humidification with PAP devices, which can assist in reducing oral dryness and other PAP-related side effects. In adults with OSA, the AASM guideline¹⁰⁰ also recommends that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy, which have shown clinically significant improvements in patient compliance with PAP therapy over time.^{106, 107}

  As an alternative course of treatment, physicians may refer OSA patients who formerly used PAP to their dentist for assessment for oral appliance therapy, a common treatment modality for individuals with mild to moderate OSA.

  Oral Appliances: Individuals with OSA can also consult with their physician and dentist to determine if an oral appliance would serve as an effective therapeutic option for treating the condition. Oral appliances may be custom-fitted by a dentist for placement in the mouth during sleep to prevent oropharyngeal tissue and the base of the tongue from recurrent collapse and blockage of the upper airway.

  Numerous oral appliances are available today, and they generally move the mandible, tongue and soft palate forward to increase pharyngeal airway space and reduce the risk of airway collapse.^{108, 109} Many terms are used to describe oral appliance therapies for obstructive sleep apnea, including mandibular advancement devices (also called mandibular advancement splints), upper airway devices and tongue-retaining devices.

  Oral appliances provide therapeutic benefit by repositioning and stabilizing the mandible, tongue, hyoid bone and soft palate in a forward position.^{110, 111} Current guidelines from the field of sleep medicine recommend that when physicians prescribe oral appliance therapy for adults with OSA, the dentist should use a custom, titratable oral appliance rather than a non-custom appliance, and should also evaluate for dental adverse effects of oral appliance use over time.¹⁰⁸

  Oral appliances have been viewed as a simpler therapeutic option for patients with OSA,¹¹² particularly for patients with mild to moderate OSA or patients with severe OSA who have difficulty tolerating PAP therapy. Patients with OSA should be advised to use their oral appliances nightly (or during each sleep session) to help achieve optimal control of OSA symptoms.

  Patients using oral appliance therapy for OSA may benefit from having an initial evaluation of the temporomandibular joint (TMJ) region to help reduce risks of adverse effects associated with long-term use of oral appliances (e.g., symptoms of TMJ disorders, changes in dental occlusion).¹¹³ Oral appliance therapy has been associated with progressive dental changes over time (e.g., reductions in overbite, overjet or mandibular crowding),¹¹⁴ as well as TMJ issues (e.g., transient morning jaw pain), hypersalivation or irritation of oral soft tissues.^{113, 115} Oral appliances can be modified to help ensure optimal fit and help the patient avoid mouth breathing, which can cause dry mouth symptoms.

  Based on the available evidence, oral appliances—specifically custom-made, titratable oral appliances--have been found to improve OSA in adult patients compared to no therapy or placebo devices.¹¹² It is appropriate for dentists to work closely with patients with OSA to determine their individual treatment needs and preferences (e.g., oral appliance recommendations may vary for heavy bruxing patients). Additional information on oral appliance therapy for OSA is presented in a 2016 Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders, which was developed by an expert panel organized by the ADA.

  Surgical Options: Surgery may be recommended for patients who do not improve or respond to non-surgical therapies for OSA. Surgical procedures are used to adjust structures (bone or soft tissues) to reduce obstruction in the upper airways, or for implantation of neurostimulator devices.

  One surgical procedure for OSA is uvulopalatopharyngoplasty, which removes or shortens the uvula, excessive tissue in the throat as well as the tonsils. Maxillary-mandibular advancement surgery is another option for expanding an individual’s upper and lower pharyngeal airway to reduce airway obstruction. Tracheostomy is another surgical intervention for OSA, but it is typically reserved for use as a potential interim treatment in select circumstances (e.g., individuals with severe OSA, or cases when other clinical options have failed or do not exist).¹¹⁶ Individuals with moderate-to-severe OSA who are unable to tolerate PAP therapy may be considered for hypoglossal nerve stimulation, which uses an implantable neurostimulator device to move the patient’s tongue forward during sleep for improved airway patency.^{117, 118}

• Dental Considerations

  A dentist can be consulted throughout the process of OSA diagnosis and treatment for patients across the lifespan. The spectrum of dental care with patients diagnosed with OSA (or at high risk for the condition) may include comprehensive oral examination, evaluation of oral anatomy and the appropriateness of providing oral appliance therapy, and other considerations.

  Health history-taking can be supplemented with use of one or more of the OSA-specific screening questionnaires, including the STOP-Bang Questionnaire and others. OSA may be considered in dental patients who report sleepiness as a common symptom. Appropriate evaluation and patient assessment, including a thorough medical and dental history, are important steps to help identify individuals at risk for clinically significant OSA. Patients determined to have significant risk of OSA (e.g., through a screening questionnaire like STOP-Bang) may be referred to a physician or sleep specialist for further evaluation.

  When conducting a standard evaluation of the patient’s oral cavity, dentists are ideally positioned to identify oral or craniofacial abnormalities or other anatomical factors (e.g., abnormalities or deviations in oral structures and tissues) that are common signs of OSA or potential risk for the condition. Features within the oral cavity that can be evaluated include large tongue, retrusive jaw, or enlarged tonsils (grade 3 or higher associated with increased risk of OSA).⁵⁷ A manual examination of the TMJ muscles and region is also recommended for evaluation of normal joint function and any associated pain.¹¹⁹ Dentists may also evaluate patients for airway obstruction in accordance with the Mallampati Scale,¹²⁰ as well as neck circumference and severe overjet.¹²¹

  Patients can be educated about the strong association between OSA and systemic hypertension, coronary artery disease and increased risk of stroke, atrial fibrillation and type 2 diabetes. Obstructive sleep apnea is commonly linked with obesity,⁴⁴ and increased body weight is associated with higher risk for OSA and increased progression and severity of the condition. When appropriate, patients suspected of having OSA should be referred to their primary care physician or sleep specialist. Some patients may benefit from seeing a registered dietician for nutritional counseling.

  Generally, dentists are advised to maintain a high level of awareness when evaluating or treating patients who present with signs or symptoms suggestive of OSA (e.g., excessive daytime sleepiness; breathing pauses during sleep that are accompanied by snorting or gasping).^{10, 122, 123} Patients with OSA may be advised to visit their dentist regularly for thorough assessment of their dental and periodontal condition, as well as fabrication and maintenance of properly fitted oral appliances that can be used safely over time.

• ADA Policy

  The ADA's policy on sleep-related breathing disorders was adopted in 2017, and can be found here: The Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders

  American Dental Association
  Adopted 2017 (2017: 269)

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• ADA Resources

  Professional Resources

  • Evidence Brief: Oral Appliances for Sleep-Related Breathing Disorders (July 2016)
  • ADA Catalog: Do You Have Sleep Apnea? Talk with Your Dentist About Snoring (Product Code W168)
  • ADA Library: Members-only journal database
    
  • JADA Archives: Sleep Apnea
    

   

  Patient Resources

  • MouthHealthy.org: Sleep Apnea and Snoring
• Other Resources
  • American Academy of Sleep Medicine: Sleep Apnea: Overview & Facts
  • American Sleep Apnea Association: Sleep Apnea Information
  • National Sleep Foundation: Sleep Apnea
  • Academy of Thoracic Surgeons: Oral Appliances for Sleep Apnea in Adults
  • American Academy of Dental Sleep Medicine: Oral Appliance Therapy
  • National Heart, Lung and Blood Institute: Sleep Apnea