● Evaluate the position of the tongue to determine if it can contribute to the development of OSA.
● Refer the patient to a physician or pediatrician who has expertise in the treatment of OSA in children and adolescents.
Upper airway resistance syndrome Upper airway resistance syndrome (UARS) is a variant of obstructive sleep apnea described in the literature, although there has been a relative paucity of research on this condition, compared with OSA. Upper airway resistance syndrome, or “ultra-mild sleep apnea,” is defined as a condition with an apnea-hypopnea index of less than 5 per hour and respiratory effort-related arousals (RERAs) greater than 5 per hour with associated fatigue. A review and treatment protocol for UARS has recently been published by Rouse (2016). Individuals with this condition tend not to be the typical OSA patients (overweight, older male). These patients more often present with malocclusion, narrow dental arches, a posteriorly displaced
maxilla, and a retrognathic mandible. Pharyngeal collapse is less severe than is seen in mild OSA. However, UARS has been shown to be progressive, worsening to OSA with advancing age, hormonal changes, and increasing body mass. According to Rouse (2016), UARS patients comprise the “vast majority of patients in dental practices with breathing-disturbed sleep” (page 321). Treatment is focused on establishing and maintaining nasal (as opposed to mouth) breathing and the use of provisional maxillomandibular advancement appliances (MMAs). Only if the patient’s airway is stabilized with the MMA is a definitive MMA fabricated.
CASE SCENARIOS
Case scenario 1 Dr. Williams, a general dentist with extensive experience treating obstructive sleep apnea (OSA), has just greeted a new patient, Ed. Ed is a rather large man: 6 feet 4 inches and at least 275 pounds. Ed is in his late forties, a father of three, and owner of his own insurance agency. He seems quite friendly but also quite stressed. (“It’s the business,” he says.) Ed also tells Dr. Williams that he has not seen a dentist in several years and was referred by a neighbor who is a patient of Dr. Williams. Dr. Williams’s encounter with Ed is raising several red flags for OSA, the first two of which are Ed’s obesity and his male gender. Another red flag goes up when Ed, who appears lethargic (as well as stressed), tells Dr. Williams that he often loses focus because he is so sleepy during the day. He is worried about making poor business decisions, as well as falling asleep while driving to see clients. Ed raises yet another red flag by mentioning to Dr. Williams that his wife tells him he snores and makes choking sounds during the night. The routine office BP screening is alarming: systolic of 197 mmHg and diastolic of 110 mmHg. A second BP measurement several minutes later is about the same. Ed also remarks that he has not seen a primary care physician in “a long time.” An initial intraoral examination reveals dentition in surprisingly good condition; there are no obvious carious lesions (radiographs will be taken later), and Ed’s periodontal status is quite good. Dr. Williams compliments Ed on his excellent home care. Unfortunately, Ed’s oral examination also displays two characteristics of OSA. The first is an enlarged tongue with scalloped lateral borders, which almost completely blocks visualization of the oropharynx. Then, when Dr. Williams uses a tongue depressor, he sees that Ed’s uvula is enlarged as well. After this initial examination, Dr. Williams and Ed meet in the dentist’s office, where they discuss the likelihood of OSA. To Dr. Williams’s astonishment, Ed states that he is not surprised by this and is interested in treatment. Dr. Williams has become the go-to dentist in his community for this disorder and is happy to accept Ed as a patient. However, because of his hectic schedule (and busy life in general), Ed wants Dr. Williams to make him an in-office, prefabricated type of sleep apnea appliance. “I have no time for staying overnight in a sleep lab, Doc,” states Ed. “Let’s just try this out and see how it goes.”
In essence, Ed is asking Dr. Williams to provide a streamlined treatment strategy. The dentist must weigh whether harm can result from taking such an approach. On one hand, there is a protocol for addressing the red flags raised during the initial consultation with Ed. On the other hand, if the prefabricated appliance does not work, Ed will see that for himself and may agree to a different approach to OSA therap y. Question: ● What should Dr. Williams’s approach be? Discussion: Dr. Williams should not fast-track Ed’s treatment. Instead, he should take the following steps to ensure that appropriate treatment is provided and convince the patient that it is worth investing the time required for effective diagnosis and treatment: 1. Ed’s elevated blood pressure readings mandate that Dr. Williams refer him to an internist or cardiologist before performing any further treatment. This is of paramount importance. 2. Williams should further review Ed’s medical history and ask whether he smokes. If he does, he should be told about the office smoking cessation program that he can join starting immediately. Dr. Williams should also suggest a weight loss program, because obesity is the primary risk factor for OSA. 3. Williams should tentatively confirm Ed’s suspicion that he has OSA. However, he must tell Ed that the diagnosis of OSA can be made only after the appropriate sleep studies are conducted. Ed must be referred to a physician who specializes in sleep medicine and is affiliated with a local sleep center. 4. To allay Ed’s concern about the time commitment involved in an in-lab sleep study, Dr. Williams can tell Ed that an at-home sleep study is a possibility but that the decision should be made by the physician who specializes in sleep medicine. 5. Williams should explain that hypertension is a serious risk factor for heart attack and stroke and that treatment for OSA has been shown to be beneficial in the treatment of high BP. 6. Williams should discuss the research findings that custom- made oral appliances, which allow for adjustable mandibular protrusion, have been shown to work significantly better than prefabricated oral appliances. However, as previously stated, the first priority should be to investigate and treat the hypertension. 7. Follow-up with the physician who specializes in sleep medicine is important so that treatment for Ed can commence as soon as a definitive diagnosis is made.
EliteLearning.com/Dental
Page 165
Powered by FlippingBook