Assoc. Dr. Hüseyin KURTULMUŞ, Prosthodontist, Dental Clinic, Alsancak, İZMİR
Sleep Apnea Syndrome (UAS); 1-5, which lasts at least 10 seconds or more due to varying degrees of collapse of the upper respiratory tract in the inspiratory phase during sleep, and 4, which is accompanied by a decrease in oxygen saturation in the blood. ,6,7 ,
Apnea is defined as the involuntary cessation of breathing. 4,8 It is also defined as 5 or more hypoapnea attacks per hour, which is a decrease in the amount of breathing
by more than 50%
. 1-4,6 Therefore, the definition of “Sleep Apnea Hypoapnea Syndrome” is another frequently used term. 1-3,9-12 In other words, UAS causes low
oxygen level in the lungs (hypoxia), oxygen desaturation in the blood and interruption of sleep in the form of arousal (between sleep-
wake) or waking. These are called apneic and/or hypopneic
events. 4
According to the results of the 2002 survey of the International Sleep Foundation (ISF), 1,4,6,8,10,13,14 is the most common complaint of sleep apnea patients, “hypersomnolance”
is interrupted sleep characterized by excessive sleepiness during the day, heavy snoring and frequent waking. On the morning of such sleep, patients usually complain of headaches, which may be the result of nocturnal CO 2
retention, muscular pain due to bruxism, nausea, and acid reflux (gastroesophageal reflux). .
Other complaints are defined as intellectual impairments, nervous behavior, tendency to argue with people around them, tendency to gluttony, depression and severe anxiety
. 1,4,6,8,10,13,14 Occupational accidents, negative impact on work performance and decreased productivity are stated as other complaints recorded. Impotence and
nocturnal enuresis have been seen in some patients. There is also restlessness and
involuntary leg movements during sleep.
Obstructive Sleep Apnea
The most common type of sleep apnea, also known as occlusive apnea, is Obstructive Sleep.
It is Apnea (OSA, Obstructive Sleep Apnea – OSA) syndrome. Oropharynx of the upper respiratory tract during sleep collapse and complete blockage (obstruction) of the ingeal part and the presence of a diaphragmatic effort (respiratory effort) during this period, accompanied by at least 10 seconds or more
recurrent apneas (in the upper respiratory tract) It is a disease that occurs when air flow stops.
1-4,7,10,15-18 Therefore, it is reported that there are local anatomical factors as well as neurological factors in the pathophysiology of OSA. It can even be said that
narrowing and obstruction of the pharyngeal air duct is the main cause of OSA (Figure 1). In most cases, this narrowing and/or obstruction occurs at the base of the tongue
. 19 When the tongue slides towards the posterior pharyngeal wall, obstruction
or narrowing occurs (Figure 2a-c). 17 When the sleep physiopathogenesis of OSA patients was examined in terms of respiratory local anatomical anomalies; In the REM (Rapidly
Eye Movement) phase of sleep, the tone of the dilator muscles of the upper airway, especially the genioglossus
muscle, decreases and the muscles relax; It is seen that the upper airways narrow further and ultimately become blocked. Thus, breathing becomes more difficult 17,20 .
Most OSA patients have distinct physical characteristics. Over-weight; It has been reported that they are short, thick and
individuals with wide necks and strong chewing muscle structure, middle-aged, smokers and alcohol users
. 4,6 In most patients, there is a decrease in lower face height
, and retrognathia, micrognathia, chin tip, and labiomental sulcus also deepen and become evident (Figure 3a,b); and sleep bruxism, deep bite, gastroesophageal reflux (Figure 4a,b). 21 Ryan et al. also showed that obese OSA patients
have a larger tongue and soft palate and therefore a smaller airway
(Figure 4c). 4,22 However, it is known that OSA can also develop in normal weight individuals. 6
Although snoring is a subject of jokes in daily life, it is a disturbing social problem that affects other family members in addition to the snoring individual
. Family
members become chronically disturbed during sleep, and this causes tensions within the family and It may cause unrest
. 10,13,14,18 However, patients complain of drowsiness and decreased professional performance during the day. During sleep, the airway narrowing that occurs due to the relaxation of the anatomical soft tissues in the oropharyngeal region of the respiratory tract cavity
increases the airflow speed. Air passing rapidly through a narrow passage; top
It creates loud sounds by vibrating the unsupported tissues of the respiratory tract 1-4,14,18,23 .
Snoring and OSA are approximately twice as common in men than in women.
In addition to gender, it is known that excessive fat accumulation also has a negative effect. 4 Sleeping
position has an effect on the morphology and upper airway dimensions
and is probably another important factor causing OSA and snoring 10,14,16,24,25
Snoring may not be associated with other sleep breathing disorders, but it may also occur as a symptom of OSA. 14 The picture usually observed in OSA patients
is snoring when they start breathing again between apnea episodes, followed by a new
obstruction.
The importance of OSA, apnea. The decrease in blood oxygen saturation during pregnancy may lead to long-term hypertension, cardiovascular and cardiopulmonary morbidity
or pose a greater risk. 6,8,10,13,14,16 In the long term, severe cases such as paralysis during sleep
sudden deaths due to cardiovascular causes such as cerebrovascular strokes and heart attack
In addition to all these, OSA; It is also considered among the predisposing factors in terms of cancer and infections. 4,8
Diagnosis of Obstructive Sleep Apnea and Snoring
Oxford questionnaire form 4,26,27,28 or Silent Nite questionnaire 18 is used as the examination form.
Especially the neck circumference measurement included in the examination form is 4, Body Mass Index
(BMI/BMI, Body Mass Index: BMI) is 10.26 and most importantly Epworth sleepiness
The data obtained by using the scale (Epwort Sleepiness Scale / Score, ESS) is very high
Laboratory Test:
2
Polysomnography (PSG) ): It is a test method applied to the patient throughout the night's sleep
and is a sleep study. is the ace. It is performed in a sleep laboratory by recording at least 4 hours of night sleep (Figure 5). Evaluating sleep and breathing patterns, determining whether patients have sleep
apnea, measuring the length and number of apneas (if any), measuring oxygen saturation, determining sleep stages, awakenings
Detection is used to monitor air flow, respiratory effort and heartbeat
(Picture 6). 1-4,6,14 Differentiating simple snoring from sleep apnea and determining the type and severity of apnea in case of detection is also possible with PSG. 7.26
Lateral Cephalometry:
During the physical examination, if a problem is detected in the maxillo-mandibular relationship and the patient is planned to be treated with an intraoral appliance
, lateral cephalometry is used in the diagnosis. It should definitely
be used. 10,29 This application is a method used to determine the degree of airway obstruction in OSA patients and for diagnostic purposes. 10,17,24,26, 30,31 .
Dentists use cephalometric radiographs. by interpreting the findings
They contribute to a multidisciplinary study approach for the treatment of OSA. Because with lateral
cephalometry, we can determine the anatomy of the OSA and/or snoring patient responsible for the obstruction,
i.e. can examine the craniofacial and obstructed pharyngeal passage (naso-oro-hypopharyngeal airway) in detail (Figure 7). 10,26,31,32
Treatment of Snoring and OSA Patients
Due to the multifactorial nature of OSA, today's treatment strategies are based on multidisciplinary
approaches. It has been reported that the team should include an ENT and head and neck surgery physician,
pulmonary medicine physician, neurologist, psychiatrist, and dentist
. Each member of the team can develop a range of different therapeutic approaches that target various elements in the pathophysiological chain. These include both surgical,
and non-invasive methods. Meyer and Knudson 17,33 described various
current options for OSA treatment as follows.
Surgical Ventilation:
Pharyngeal soft tissue surgeries. 4,17,18,34
Nasal Continuous Positive Airway Pressure tive Airway
NCPAP uses a small hose and air pump (generator) connected to a closed face or nasal mask (Figure 8) to provide patients with a gentle and continuous flow
during sleep.It is a method of providing a constant moist air flow filtered under pressure (7-10 cm H 2 O pressure)
. 1-4,10,14 It prevents soft tissues from collapsing and obstructing the respiratory tract,
It also reduces the negative pressure during inspiration. 1-4,10
Behavioral Regulations:
Non-surgical non-invasive treatments; reducing body weight by losing weight,
avoiding the use of cigarettes, alcohol (especially at night) - sedative and hypnotic drugs (central nervous system depressants)
19, improving head posture with head and neck extension collars
It includes conservative approaches such as changing the sleeping environment and behavioral modifications such as sleeping position.
4,10,14,16,17,35
Intraoral Appliances:
3
Clinic on the use of intraoral appliances for the treatment of snoring
Studies started in North America in the early 1980s. These early period
applications include palate lifters, tongue repositioners (device that keeps the tongue forward
: Tongue Retaining Device: TRD) and devices that bring the mandible forward (mandibular
Since appliances that bring the mandible forward have been shown to be more comfortable and effective, the majority of subsequent studies have focused on the use of these appliances. 14
Nowadays, the idea of using it as an alternative treatment option is gaining increasing attention
. 9,10,26,30 Today, many commercially produced commercial apparatus
are available on the market (Picture 9). 4
Individually; Devices that bring the mandible forward, described by Robin in 1934, can be fixed and single-piece or adjustable, double-piece and more
complex. 4,14,37 When using monoblock intraoral appliances, the clinician determines the amount of mandibular advancement required.
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