In patients with OSA, anatomic factors resulting in narrowing of the upper airway have been evaluated by imaging (Sharma, 2019; Yilmaz, et al., 2021). Among the features identified are increased lateral wall thickness and fat pad size, with consequent reduction in the lateral diameter and cross-sectional area of the retropharyngeal airway. Other radiographic signs include (a) increased distance between the mandibular plane and the hyoid bone; (b) posterior displacement of the symphysis; Signs and symptoms Classic features of OSA include irregular and abnormal respiratory patterns during sleep. Gasping or choking during sleep is the most reliable indicator of OSA, whereas snoring, although common among sleep apnea patients, is not useful in establishing a diagnosis as most people who snore do not have OSA (Kline, 2021). A Finnish study of 5,177 adults used self-reported simple snoring and OSA, along with various markers of SDB and traditional risk factors to assess cardiovascular risk (Niiranen, Kronholm, Rissanen, Partinen, & Jula, 2016). Self-reported simple snoring by itself was not associated with future cardiovascular events. However, among snorers, frequent breathing cessations and very loud and irregular snoring were associated with cardiovascular risk. Major symptoms of OSA are those attributable to impaired sleep: excessive daytime sleepiness and decreased cognitive functioning (Kline, 2021). Dentists, dental hygienists, and dental assistants are alerted to the possibility that a patient has OSA when the patient complains of daytime sleepiness or the bed partner reports loud snoring, gasping, choking, snorting, or other interruptions of breathing while sleeping (Kline, 2021). Obesity, as noted earlier, is considered the primary risk factor for OSA.
and (c) abnormal relationships among the tongue base, soft palate, cranial base, pterygoid processes, and cervical spine (Poss, 2016). Cone beam computed tomography is a valuable tool for identifying patients with anatomic characteristics of OSA however the volume of the upper airway as an isolated parameter was not correlated with the severity of the OSA (Rodrigues, et al., 2018). The dental professional should strongly consider referring the patient with relevant indicators to a sleep specialist or sleep center. It can then be determined whether a polysomnogram (PSG) is indicated. The PSG is the most commonly used test in the diagnosis of sleep breathing disorders and is considered the gold standard in diagnosing the disorder (Kapur et al., 2017; Kline 2021; Laratta, et al., 2017). Polysomnography usually requires overnight monitoring in a sleep laboratory. The PSG employs multichannel recordings of sleep time, sleep stages, respiratory effort, airflow, cardiac rhythm, oximetry, and limb movements. The resultant AHI is the most crucial information which is used to diagnose OSA (Hsieh, et al., 2020). A portable, at-home sleep monitor can be used as an alternative to a sleep laboratory PSG. The portable monitor cannot determine the actual sleep time and thus does not give the AHI. Instead, the at-home sleep study provides the respiratory disturbance index (RDI), which is the frequency of apnea and hypopnea per hour of recording time. The RDI tends to underrepresent the severity of OSA, and a negative result from a portable monitor does not necessarily rule out OSA. A portable at-home sleep study for patients with a high pretest likelihood for moderate to severe OSA without other substantial comorbid conditions is an appropriate alternative to in-laboratory polysomnography (Kline, 2021).
TREATMENT OF OBSTRUCTIVE SLEEP APNEA
The goals of OSA treatment are to decrease or resolve the primary signs and symptoms of the disorder, namely, to normalize the AHI and oxyhemoglobin saturation levels and to improve sleep quality (Kryger & Malhotra, 2018). Obstructive sleep apnea should be treated as a chronic disease, requiring long-term multidisciplinary treatment. According to the Adult Obstructive Sleep Apnea Task Force of the AASM: The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of Behavior modifications Behavioral changes have been shown to help OSA. These include weight loss and exercise, avoidance of alcohol and certain medications (e.g., benzodiazepines), and sleeping in a Continuous positive airway pressure Continuous positive airway pressure (CPAP) is a treatment method that employs a device to increase air pressure in the throat to prevent airway collapse. A CPAP device acts as a pneumatic force to brace open the airway, providing continuous positive pressure to the upper airway during sleep. By stabilizing the airway walls, CPAP therapy alleviates the tendency for the upper airway to collapse, ameliorating breathing disturbances. Continuous positive airway pressure is the primary treatment modality for adults with OSA and is considered the gold standard of treatment (Pavwoski and Shelgikar, 2017). CPAP is indicated for patients diagnosed with moderate to severe OSA (Chanine and Wright, 2021; Laratta, et al., 2017). Well-designed studies have shown that CPAP therapy improves daytime function, subjective and objective measures of daytime sleepiness, and quality of life in patients with SDB (Harward and Speer, 2019; Laratta, et al., 2017). Therapy with CPAP causes
sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment (Espstein et al., 2009 p. 264) . Practice parameters for the treatment of OSA have been published by the AASM (Singh, et al., 2019; BCGuidelines. ca, 2021; American Medical Association, 2017; Semelka, et al., 2016), published a review of the various treatment options for OSA, which include behavior modifications, continuous positive airway pressure, oral appliances, surgical procedures, and medications.
nonsupine position. These strategies apply to all levels of OSA (Kryger, 2018).
a statistically significant reduction in BP in patients with OSA (though the actual difference was not great), particularly for those experiencing frequent apneic episodes (Dieltjens and Vanderveken, 2019). Peker and colleagues (2016) conducted a prospective, randomized controlled clinical trial to determine the effects of CPAP on long-term cardiovascular outcome risk in patients with coronary artery disease (CAD) and nonsleepy OSA. A significant cardiovascular risk reduction was found in patients who used CPAP for longer than 4 hours a night compared with those who used CPAP for fewer than 4 hours a night or who did not receive treatment. Research on the effects of CPAP on Type 2 diabetes (i.e., insulin resistance) have yielded conflicting results (Mok, et al., 2017; Reutrakul and Mokhlesi, 2020). Insulin sensitivity has been shown to improve within 2 days of starting CPAP therapy in non-
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