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Compendium
March 2016
Volume 37, Issue 3

Other research has also suggested that CBCT airway analysis could be useful in assessing the presence and severity of obstructive sleep apnea, noting that these parameters are associated with a narrow lateral dimension of the airway, among other individual traits.15 What’s interesting to note, however, is that what may affect the accuracy and utility of CBCT scans in dental sleep medicine is the position in which the patient is situated at the time the scans are taken. Whereas images taken with the patient in an upright position (eg, cephalometric views) do not realistically reflect a patient’s airway during sleeping, the supine position required for CBCTs may enable more accurate assessment of airway, soft palate, and volumetric measurements and identification of obstruction locations.15

Treatments for Sleep-Disordered Breathing

The results of these radiographic-based investigations suggest that using CBCTs in screening, diagnosing, and treatment planning patients with sleep-disordered breathing—and particularly obstructive sleep apnea—can be beneficial, especially prior to planning surgical interventions. They also underscore the need to consider the location of the obstruction along the airway to ensure treatment efficacy.16 For example, the further down the airway an obstruction is located, the less likely that an oral appliance will be effective in treating the sleep-disordered breathing condition.16

Continuous Positive Airway Pressure (CPAP)

The most prescribed and recommended treatment for moderate to severe obstructive sleep apnea is continuous positive airway pressure (CPAP). With a 70% acceptance rate, CPAP machines require patients to wear a mask during nighttime sleep. The unit introduces air into a person’s nasal passage and exerts positive pressure to open the upper airway, which enables him or her to breathe.11

Appliance Therapy

Oral appliances have been widely used to treat sleep-disordered breathing and have been shown to lessen the severity of the condition by 60%; additionally, like CPAP machines, they have an acceptance rate of approximately 70%.17,18 Currently, there are more than 40 types of oral appliances available, all categorized according to their design or mechanism of action (eg, tongue-retaining or mandibular advancement).

Mandibular advancement oral appliances (either fixed or adjustable) have been the nonsurgical method of choice and shown to be successful in the treatment of sleep-disordered breathing when patients cannot tolerate CPAP machines and have mild to moderate sleep apnea (Figure 2).1,9-11,16-18 In fact, mandibular advancement devices have been shown to reduce both systolic and diastolic blood pressure among patients with obstructive sleep apnea,16 as well as improve blood oxygen saturation levels and reduce apnea-hypopnea index.11 However, these devices may present complications, including occlusal changes, temporomandibular joint discomfort, fabrication issues, and high cost.19

Additionally, despite the relatively high acceptance rate associated with oral appliances, consistent patient compliance in terms of nightly wear remains an issue. An oral device (SomnoDent® with CR, SomnoMed, www.somnomed.com), however, was recently introduced that incorporates some of the compliance features used with a CPAP. Designed specifically to objectively record compliance measurements when patients use the oral appliance to treat obstructive sleep apnea, the device contains a thermal sensor and accelerometer “chip” (DentiTrac®) embedded and sealed within it to measure hours worn and record head position.20

Surgical Interventions

Upper airway surgery is considered the last resort and reserved for patients who have not responded to other available treatment options (eg, CPAP, oral appliance). The variety of surgeries performed to reduce upper airway obstructions range from those focused on nasal obstructions (ie, septoplasty, turbinectomy, turbinate radiofrequency ablation) to those that reduce soft-palate redundancy (ie, uvulopalatopharyngoplasy, uvulopalatal flap, laser-assisted uvulopalatoplasty, and soft-palate radiofrequency ablation with adenotonsillectomy).21 More drastic procedures for more severe cases of obstructive sleep apnea include genioglossal advancement, hyoid suspension, distraction osteogenesis, tongue radiofrequency ablation, lingualplasty, and maxillomandibular advancement.21

Nasal surgeries—Nasal surgeries address obstructions created by hypertrophied, cartilaginous, or bony tissues in the nasal airway.21 Although they cannot significantly improve sleep breathing in patients with moderate to severe sleep-disordered breathing, nasal surgeries do help to enhance CPAP compliance, as well as prevent or minimize the mouth breathing that can ultimately force the tongue into the posterior pharyngeal area, thereby exacerbating sleep breathing conditions.

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