HJAR Jul/Aug 2022

HEALTHCARE JOURNAL OF ARKANSAS I  JUL / AUG 2022 51 should be determined by a physician. 10 There are many objective and subjective tests for OSA. Polysomnography is an objective test and the gold standard for identifying OSA. This is a sleep study in which electrodes are at- tached to the face, eyes, and scalp to mea- sure brain waves while a patient sleeps. 11 The severity of OSA is classified based on the average numbers of apneas (temporary ces- sation of breath) and hypopneas (shallow or reduced breath) per hour of sleep. This is referred to as the Apnea-Hypopnea Index (AHI). Anormal AHI is <5, and a severe AHI is >30. [see table 1, AHI Index] The subjective tests are questionnaires such as the Berlin Questionnaire and STOP-Bang, used to diagnose sleep apnea in a clinical scenario. The Epworth Sleeping Scale (ESS) is used to determine excessive daytime sleepiness. The ESS is a useful tool to assess the patient for the likelihood of falling asleep on a 4-point scale. Once the patient has been diagnosed as having OSA, options are considered for treatment. These consist of Continuous Positive Airway Pressure (CPAP), pharmacotherapy, surgical management, and oral appliance therapy. For the patient who has severe OSA, the CPAP is the gold standard for treatment. The CPAP provides air pressure high enough to prevent collapse of the airway, with air flow- ing through a mask that seals around the mouth or nose. The CPAP is proven to be the treatment of choice in reducing apnea- hypopnea indices and oxygen desaturation. 12 Niki Carter, DMD, MPH Dental Director Delta Dental of Arkansas good night’s rest. OSA is one of many disor- ders where it is paramount that the medi- cal and dental disciplines work together in yielding positive outcomes and treat in the best interest of the patient. n REFERENCES 1 Irwin, M.R. “Why Sleep Is Important for Health: A Psychoneuroimmunology Perspective.” Annual Re- view of Psychology, 66 (Jan. 2015): 143–172. https:// doi.org/10.1146/annurev-psych-010213-115205 2 National Safety Council. “Drivers Are Falling Asleep Behind the Wheel.” https://www.nsc.org/road-safety/ safety-topics/fatigued-driving. 3 Goodchild, T.T.; Lefer, D.J. (2020). “Obstructive Sleep Apnea: The Not-So-Silent Killer.” Circulation Research, 126, no.2 (Jan. 17, 2020): 229–231. doi: 10.1161/CIRCRESAHA.119.316359 4 Yaggi, H.K.; Concato, J.; Kernan, W.N; et al. “Ob- structive sleep apnea as a risk factor for stroke and death.” New England Journal of Medicine 353, no.19 (Nov. 10, 2005): 2034-41. https://pubmed.ncbi.nlm. nih.gov/16282178/ 5 Javaheri, S.; Barbe, F.; Campos-Rodriguez, F., et al. “Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences.” Jour- nal of the American College of Cardiology, 69, no.7, (2017): 841–858. https://doi.org/10.1016/ j.jacc.2016.11.069 6 Lai, V.; Carberry, J.C.; Eckert, D.J. “Sleep Apnea Phe- notyping: Implications for Dental Sleep Medicine.” Journal of Dental Sleep Medicine 6, no.2 (2019). 7 Park, J. G.; Ramar, K.; Olson, E. J. “Updates on defi- nition, consequences, and management of obstruc- tive sleep apnea.” Mayo Clinic Proceedings, 86, no.6 (June 1, 2011): 549–555. https://doi.org/10.4065/ mcp.2010.0810 8 Kline, L.R. “Clinical presentation and diagnosis of obstructive sleep apnea in adults.” UpToDate. Last updated June 1, 2022. https://www.uptodate.com/ contents/clinical-presentation-and-diagnosis-of-ob- structive-sleep-apnea-in-adults 9 Lobbezoo, F.; de Vries, N.; de Lange, J.; Aarab, G. “A Further Introduction to Dental Sleep Medicine.” Na- ture and Science of Sleep 12 (Dec. 14, 2020):1173-1179. doi: 10.2147/NSS.S276425. 10 Levine,M.;Bennett,K.;Cantwell,M.;etal.“DentalSleep Medicine Standards for Screening, Treating, and Man- aging Adults with Sleep-Related Breathing Disorders.” Journal of Dental Sleep Medicine 5, no.3 (2018): 61-68. https://aadsm.org/docs/jdsm.7.10.sa1.pdf 11 Arora, S. A.; Kochhar, R.; Narang, S.; Saurav, K. “Sleep Related Breathing Disorders: What & Why A Dentist Should Know? An Overview of Dental Sleep Medicine. National Journal of Inte- grated Research in Medicine 6, no.5 (2018): 94-102. http://nicpd.ac.in/ojs-/index.php/njirm/article/ view/976 12 Semelka, M.; Wilson, J.; Floyd, R. “Diagnosis and Treatment of Obstructive Sleep Apnea in Adults.” American Family Physician 94, no.5 (Sept. 1, 2016):355-60. PMID: 27583421. 13 Mayo Clinic. “CPAP machines: Tips for avoiding 10 common problems.” Oct. 27, 2021. https://www. mayoclinic.org/diseases-conditions/sleep-apnea/in- depth/cpap/art-20044164 14 Sheats, R.D.; Schell, T.G.; Blanton, A.O.; et al. “Man- agement of Side Effects of Oral Appliance Therapy for Sleep-Disordered Breathing. “Journal of Dental Sleep Medicine 4, no.4 (2017):111–125. http://dx.doi. org/10.15331/jdsm.6746 Quality of life indices appear to be similar to oral appliance therapy, however, some cannot tolerate the CPAP and seek other options. 13 Prescription medicine to induce sleep is a secondary alternative, combined with weight loss if this is the main cause. Surgical management to correct nasal abnormalities, tonsillectomy, or reducing/removing the uvula are also options. Maxillomandibular advancement is a corrective surgery to bring the mandible forward. This can involve orthodontia, and the majority of adults do not elect this type of treatment. Oral Appliance Therapy (OAT) is accomplished by the dentist who constructs the appliance based on the physician’s prescription. There are tongue-retaining devices and mandibular advancement devises. The most common is the appliance that pulls the mandible forward, thereby opening up the airway. The appliance must be fitted and adjusted to make sure it is comfortable for the patient to wear. These appliances are not without issues, as the bite can change. Often times, there is a morning occlusal guide placed after the patient wears the OAT all night. 14 This occlusal guide must be worn for several minutes each morning upon wakening and repositions the bite to the patient’s natural occlusal position. After fitting the appliance, follow-up is essential tomake sure the patient is not having issues wearing the OAT and will remain compliant. This field concerning dental sleep medi- cine has evolved over the past several years and offers the OSA patient options to get a Table 1 AHI Index Classification of severity of OSA Class-I Class-II Class-III Class-IV Soft palate Uvula Hard palate Pillar AHI Rating <5 Normal (no Sleep Apnea) 5-15 Mild Sleep Apnea 15-30 Moderate Sleep Apnea >30 Severe Sleep Apnea Fig. 1 Mallampati Classification