Case scenario 2 Susan is a 52-year-old female patient of Dr. Smith. Because Susan presents with several classic signs and symptoms of OSA, Dr. Smith recommends that she undergo an overnight PSG sleep study to more definitively diagnose her condition. Susan is referred to a physician who specializes in sleep medicine and, under his supervision, has the PSG. The resulting AHI of 12 events of apnea or hypopnea per hour gives a diagnosis of mild to moderate OSA. Oral appliance therapy is indicated for patients like Susan. Because an OA is generally better tolerated than CPAP, treatment with OA is often the first-line therapy for mild to moderate OSA. Dr. Smith delivers a custom, laboratory- fabricated OA that permits titration of mandibular protrusion. Based on the readings on a George Gauge, Dr. Smith sets the initial degree of protrusion. This protocol is standard procedure for Dr. Smith, who has successfully treated many patients with the same type of OA and the same protocol for its fabrication and use. Unfortunately, Susan experiences little or no subjective improvement in her sleep apnea symptoms. She is worried that the next step will be some type of palatal or other surgery, which she would prefer to avoid. Question: ● What should Dr. Smith’s next steps be? Discussion: Dr. Smith should offer positive encouragement to Susan. He should tell her that surgery for OSA is usually the last resort and that other options are available. Dr. Smith should confirm that Susan’s compliance is acceptable (i.e., that she is using the OA every night). Dr. Smith should also re-educate Susan on some of the behavioral changes she could make that have been shown to help OSA (e.g., weight loss, changing sleeping position from Glossry ● Apnea : Cessation of airflow for at least 10 seconds. ● Apnea-Hypopnea Index (AHI) : Average number of apnea and hypopnea events per hour of sleep. ● Continuous Positive Airway Pressure (CPAP) : Treatment involving a machine that functions as pneumatic (i.e., using air pressure) support, allowing maintenance of upper airway patency. Administered through a nasal or oronasal mask, CPAP is the gold standard for the treatment of OSA. ● George Gauge : A device invented by orthodontist Dr. Peter T. George, which can be used to set a predetermined degree of mandibular protrusion before taking a bite registration. ● Hypopnea : Reduction in airflow with a resultant oxygen desaturation of at least 4%. ● Mandibular Advancement Device (MAD): The most commonly used oral appliance for the treatment of obstructive sleep apnea; also known as the mandibular advancement splint or mandibular repositioning appliance . ● Obstructive Sleep Apnea (OSA) : Apnea-hypopnea index (AHI) of 5 or greater, with associated symptoms (e.g., excessive daytime sleepiness), or AHI of 15 or greater, regardless of symptoms. ● Oral Appliance (OA) : Device that protrudes and stabilizes the mandible to maintain a patent upper airway during sleep. The most commonly used OA is the mandibular advancement device (MAD), also known as a mandibular advancement splint or mandibular repositioning appliance. Resources Dental professionals seeking to learn more about obstructive sleep apnea (OSA) can contact organizations involved with sleep medicine and the treatment of sleep disorders. Among them are the following: ● American Academy of Sleep Medicine (AASM) Website: https://aasm.org/ ● American Academy of Dental Sleep Medicine (AADSM) Website: https://www.aadsm.org/
supine to lying on her side, and the avoidance of alcohol and tobacco). If applicable, Susan should embark on a weight loss program, because obesity is the major risk factor for obstructive sleep apnea. Changing to a different type of OA would be a reasonable next step, because some patients respond better to a particular type of appliance. Appliance selection is currently made empirically, that is, by clinical trial and error. The downside of this approach is the cost of potentially fabricating multiple appliances. Furthermore, Dr. Smith knows that the success rate for OAs ranges from 30% to 85%, depending on multiple factors, including success criteria, patient selection, and type of appliance. Dr. Smith should discuss these issues with Susan, as with all OA patients. It is conceivable that Susan is simply among the patients who are not helped to a significant degree by an OA. Susan should be comforted to learn that, before surgery is considered, CPAP is usually the next step in treatment. Before Dr. Smith decides on an alternate course of action for Susan, he should consult with the sleep physician who supervised and analyzed Susan’s PSG. A possible approach would be another overnight polysomnographic sleep study, using a remotely titratable appliance. The amount of protrusion of this OA is controlled during the sleep study. The various parameters of sleep apnea (e.g., oxygen saturation) are measured concurrently with the appliance titration to optimize the amount of mandibular protrusion. Upon consultation with Susan and her sleep physician, the appropriate course of action can be decided. ● Polysomnogram (PSG) : The most commonly used test in the diagnosis of sleep breathing disorders. ● Respiratory Disturbance Index (RDI) : Average number of apnea and hypopnea events per hour of recording time when recorded by a portable at-home sleep monitor (rather than sleep time, which cannot be measured using this type of monitor). Because the total recording time often exceeds the sleep time, the RDI from portable monitors often underrepresents the severity of OSA. ● Respiratory Effort-Related Arousals (RERAs) : Abnormal upper airway functions during sleep that do not score as apnea on a polysomnogram, yet create stress on the neural and neuroendocrine systems and precipitate somatic and systemic problems found in sleep apnea patients. ● Sleep-Disordered Breathing (SDB) : A common disorder, or group of disorders, causing a range of substantial harmful clinical, social, and economic sequelae. Sleep-disordered breathing occurs when an individual periodically stops breathing or breathes too slowly or shallowly while asleep. ● Tongue Repositioning Device (TRD) : Apparatus designed to hold the tongue forward with suction, via a flexible oral bulb. ● Upper Airway Resistance Syndrome (UARS) : “Ultra-mild” sleep apnea, with an apnea-hypopnea index of less than 5 per hour and more than 5 respiratory effort-related arousals per hour with associated fatigue.
● American Sleep Apnea Association Website: https://www.sleepapnea.org/
Patients who have a sleep disorder such as OSA or who want further information can contact the following organization: ● MyApnea.org (Brigham and Women’s Hospital, Division of Sleep and Circadian Disorders) Website: https://myapnea.org/
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