Dental Tribune US Edition, Vol. 5, No. 19

Clinical DENTAL TRIBUNE | September 201010A f DT page 9A has been determined. Patients that are diagnosed with severe OSA should be encouraged by the dentist and sleep specialist to wear the CPAP device. This device consists of an air compres- sor that blows air up the patient’s nose and forces air into the lungs. It is extremely effective when it is worn faithfully every night, however, the problem is that approximately 60 to 70 percent of patients cannot toler- ate the CPAP device after one year. If the patient has mild to moderate OSA or cannot tolerate the CPAP device, then dentists are encouraged to treat these patients with oral appliances. There is also a high correlation between patients who have GERD (gastroesophageal reflux)1 and OSA. With regard to diabetes, excessive apneic events affect the production of insulin, which encourages the onset of type 2 diabetes.2 These apneic events also affect the permeability of the endothelial lining of the arteries. This increases the buildup of plaque in the arteries and the chance of cardiovascular complications such as a heart attack. The weakening of the walls of the arteries increases the susceptibility of rupturing of these ves- sels which occurs during strokes.3 Nasal obstruction Before treatment, clinicians must determine whether or not there are any nasal obstructions that would interfere with the patient’s ability to breathe through his/her nose. If the patient is a chronic mouth breather, the patient should be referred to an ENT specialist to check for a deviated septum, enlarged turbinates, polyps or other nasal obstructions. A determination must be made whether or not the nasal mucosa is swollen due to allergies, which might cause a nasal obstruction.4 In our office, we have a diagnostic device known as a rhinometer5 that is an initial screening device to deter- mine if there is a nasal obstruction in either nostril. The rhinometer is an accurate, non-invasive device that evaluates the potential obstruction by sending sound waves up the nose and any obstructions are recorded on a computer.6 Hypopharyngeal obstructions Our office uses a pharyngometer to diagnose the size of the airway dur- ing the daytime as well as nighttime.7 It is used at the initial appointment to check the patient’s normal airway (daytime) and the collapsed airway (nighttime). To assess the size of the collapsed airway at night, the patient is instructed to exhale all the air from his/her lungs and a measurement of the airway is taken. The normal size of a collapsed air- way is 2.0 cm. Patients with OSA usu- ally have a much smaller collapsed airway. Bite registrations in different positions are taken to see how much the airway may be increased. By moving the mandible forward at different vertical heights, we deter- mine if the oral appliance will open the airway in that position signifi- cantly. In most cases, when a bite reg- istration reveals that the airway opens significantly when the oral appliance is fabricated in that position, the treat- ment is usually successful. Oral appliances Oral appliances are extremely effec- tive in eliminating snoring and OSA, particularly in patients with mild to moderate OSA.8 They function by moving the lower jaw and, conse- quently the tongue, forward to open up the airway.9 They hold the lower jaw forward when the patient sleeps on his/her back, which keeps the air- way open all night. The literature is replete with arti- cles regarding the effectiveness of dif- ferent oral appliances.10 Patients find that oral appliances are extremely comfortable to wear. Three different oral appliances that are used to prevent snoring and OSA include Respire, EMA and the Suad appliance. The appliances all work essentially the same way by gradually moving the lower jaw forward in small increments and increasing the vertical dimension, which ultimately increases the size of the pharyngeal airway. It is imperative that dentists learn to treat patients with mild to moder- ate OSA and those who cannot tol- erate the CPAP device.11 There are thousands of patients who have been diagnosed with OSA and cannot wear the CPAP. The health of these patients is continuing to deteriorate and their life expectancy shortened while the dental profession holds the key to their treatment. I have treated many patients with severe OSA who could not wear the CPAP device and successfully reduced their apneic events below five times per hour, which is normal. This treat- ment certainly improves their health and prolongs their life by reducing their blood pressure and their suscep- tibility to heart attack, stroke and type 2 diabetes.12 Conclusion The prevalence of OSA is exceedingly high in first-world countries mainly due to the increase in the rate of obe- sity. An estimated 25 percent of males and 9 percent of females will develop obstructive sleep apnea in their life- time.13 It is important for the dental profes- sion to educate their staff and them- selves so they can learn to diagnose and treat the large number of appro- priate patients with oral appliances. The failure rate with CPAP is close to 70 percent, which means a large number of patients will seek alter- native treatment. The medical and dental profession has not done an adequate job in educating the CPAP failure patients about the existence of oral appliances as an alternative. Dentists can significantly improve the health of these patients and the profession must get involved now when the need is so critical. DT A complete list of references is avail- able from the publisher. Fig. 1: This is what happens to those who suffer from sleep apnea: the tongue complete blocks the airway. (Photo/Provided by Dr. Rondeau) Fig. 5: This is a dorsal type appli- ance composed of two pieces (www. respiremedical.com). (Photo/Pro- vided by Dr. Rondeau) Fig. 6: One of three appliances used to prevent snoring and OSA. The elastic mandibular advancement (EMA) appliance. (Photo/Provided by Dr. Rondeau) Fig. 2: This is what happens to those who snore: the tongue partially blocks the airway and causes the palatal tissues to vibrate. (Photo/ Provided by Dr. Rondeau) Snoring Fig. 3: A pharyngometer. (Photo/ Provided by Sleep Group Solutions) Dr. Brock Rondeau is one of North America’s most sought after clinicians and lectures more than 100 days per year. He is a master senior certified instructor for the International Association for Orthodontics and its past president. More than 19,000 dentists have attended his courses and study clubs in the United States, Canada, China, Australia, Eng- land and Poland. He has a busy practice limited to the treatment of patients with orthodontic, snoring and sleep apnea and TMJ problems. Ron- deau is a diplomate of the Inter- national Board of Orthodontics and a diplomate of the American Academy of Craniofacial Pain. For more information about his seminars and to contact him, please visit www.rondeau seminars.com. About the author Fig. 4 (Photo/Provided by Sleep Group Solutions) Sleep apnea