JPOR-276; No. of Pages 11 journal of prosthodontic research xxx (2015) xxx–xxx

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Review

Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea Shuji Shigemoto DDS, PhDa,b, Yuko Shigeta DDS, PhDb,*, Jun Nejima MD, PhDc, Takumi Ogawa DDS, PhDb, Yoshizo Matsuka DDS, PhDa, Glenn T. Clark DDS, MSd a

Department of Fixed Prosthodontics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan b Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, Yokohama, Japan c Department of Internal Medicine, Tsurumi University School of Dental Medicine, Yokohama, Japan d Orofacial Pain/Oral Medicine Center, Division of Diagnostic Sciences, Ostrow School of Dentistry, University of Southern California, Los Angeles, USA

article info

abstract

Article history:

Purpose: This review article covers the diagnosis and treatment of obstructive sleep apnea

Received 9 March 2015

(OSA) from a dental perspective. It addresses the issue of when and how to screen for and

Received in revised form

then, if indicated, refer the patient for a more comprehensive.

9 April 2015

Study selection: Our focus in this article was on identifying current unanswered questions

Accepted 10 April 2015

that relevant to OSA problems that dental scientists have to pursue and on providing

Available online xxx

valuable information on that problems, consequently the previous studies which investigated or reviewed the diagnosis and treatment of OSA were included. In addition, we

Keywords:

included studies on jaw movements during sleep and on the use of a lateral cephalometric

Obstructive sleep apnea

film related to the diagnosis and treatment of OSA.

Diagnosis

Results: The role of portable sleep monitoring devices versus full laboratory polysomno-

Treatment

graphy is discussed. This review also describes what is known about the efficacy of

Jaw movements

mandibular advancement devices and when and how they fit in to a treatment program

Cephalometric image

for a patient with obstructive sleep apnea. Finally some basic research is presented on jaw movements during sleep and how a lateral cephalometric film can be used to assess the changes of the airway with body posture and head posture. Conclusion: This article provides the valuable suggestions for the clinical questions in the diagnosis and treatment of OSA. # 2015 Published by Elsevier Ireland on behalf of Japan Prosthodontic Society.

* Corresponding author at: Department of Fixed Prosthodontics, School of Dental Medicine, Tsurumi University, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama, Japan. Tel.: +81 45 580 8417; fax: +81 45 573 9599. E-mail address: [email protected] (Y. Shigeta). http://dx.doi.org/10.1016/j.jpor.2015.04.002 1883-1958/# 2015 Published by Elsevier Ireland on behalf of Japan Prosthodontic Society.

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Contents 1. 2.

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1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical diagnosis and management for obstructive sleep apnea (OSA). . . 2.1. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Treatment with a mandibular advancement device. . . . . . . . . . . . . 2.3. Unanswered questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jaw movement during sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Techniques of evaluating airway configuration on cephalometric images 4.1. Change of the airway with body posture . . . . . . . . . . . . . . . . . . . . . 4.2. Change of the airway with head posture . . . . . . . . . . . . . . . . . . . . . 4.3. Correction of airway width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction

There are multiple unanswered questions that are relevant to obstructive sleep apnea problems that dental scientists have to pursue. Once these questions are answered, dental and other health care clinicians need to figure out how and when to apply the suggested solutions on their patients. In this review, several of these questions are addressed. For example, the question: ‘‘Should dentists incorporate a sleep breathing disorder screening examination into their work-up of a new patient?’’ is discussed. Second, if the answer to the prior question is positive, then the next logical questions is: ‘‘What is the best method to screen dental patients and when is it appropriate to refer a patient for comprehensive diagnosis of their possible obstructive sleep apnea disorder?’’ This review lays out the suggested process for such a work-up. Once a clinically important obstructive sleep apnea problem is confirmed, then the next logical questions is: ‘‘How is it best treated?’’ In this review there is a discussion of what has been recommended as a first and second line treatments and specifically, what is the role of a mandibular advancement device (MAD) are in this treatment algorithm. Of course there are many questions about co-morbid conditions where the answers are yet to be determined. For example, ‘‘What is the significance of the relationship between sleep bruxism and obstructive sleep apnea?’’ Another unanswered question is: ‘‘What is the relationship between gastroesophageal reflux disease (GERD) and obstructive sleep apnea?’’ A third important unanswered question is: ‘‘What is the impact of orofacial pain and/or temporomandibular disorders and headache on sleep apnea treatment and vice versa?’’ All three of these questions will require more investigations. This review discusses in detail the role of a mandibular advancement device as a treatment. Finally this review discusses new scientific findings on (1) airway imaging collected with a lateral cephalometric radiograph and (2) the motion of the jaw during sleep.

2. Clinical diagnosis and management for obstructive sleep apnea (OSA) Because obstructive sleep apnea is a growing concern in health care and untreated, it can cause major health problems,

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this review suggests that dentists should indeed screen their new patients for this disorder. One of the most efficient screening methods for obstructive sleep apnea in a dental setting is a questionnaire and there are several validated questionnaires to choose from. Two of the best are the StopBang Questionnaire and the Berlin Questionnaire [1,2] (Fig. 1). Once a patient with possible OSA is identified via one of these questionnaires, the next step is to get a proper diagnosis. In 2009, American Academy of Sleep Medicine (AASM) developed clinical guidelines for obstructive sleep apnea (OSA) [3], so as to provide evidence-based recommendations. These authors reviewed available literature and presented a recommended diagnostic and a treatment strategy. The diagnostic strategy included collecting data via a sleep-oriented questionnaire, sleep oriented history and physical examination, and objective testing (in-laboratory polysomnography (PSG) and home testing with portable monitor) and education of the patient. These data allow the severity of the sleep disorder to be determined and by knowing the severity, a better recommendation for correct treatment can then be made. First line options for treatment include continuous positive airway pressure (CPAP) device and a mandibular advancement device (MAD). Second line options for treatment include behavioral treatments, surgery, and/or other adjunctive treatments. In 2013 and 2014, two additional clinical guidelines [4,5] of OSA in adults were developed by the American College of Physicians (ACP). These guidelines also provide clinical recommendations on diagnosis and management of OSA in adult. The authors recommended PSG for diagnostic testing in patients suspected OSA. The portable sleep monitors (PMs) are also recommended in patients without serious comorbidities as an alternative to PSG. Of course not all portable monitors are the same and are classified into 3 types (Type II: comprehensive portable PSG, Type III: Modified portable sleep apnea testing, and Type IV: continuous single- or dualbioparameter recording) [6]. PSG and PM data both measure or estimate the apnea–hypopnea index (AHI), that is the number of apnea or hypopnea events per hour of sleep time. These data are then used to evaluate the severity of OSA. The AASM sets a threshold and defined OSA severity as mild for AHI 5 and 30/h. The Respiratory Disturbance Index (RDI) has, at times, been used synonymously with AHI. When a PM is used that does not measure sleep staging, the RDI refers to the number

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Fig. 1 – Stop-Bang Questionnaire (Left) and the Berlin Questionnaire (Right).

of apnea or hypopnea events per hour of recording [7]. In the former guidelines, CPAP treatment is strongly recommended as initial therapy for patients diagnosed with OSA. The MADs are also recommended as an alternative therapy to CPAP therapy and consider it a first-line treatment choice for (1) severe snoring, (2) mild to moderate OSA patients and (3) in more severe OSA patients who fail treatment attempt with CPAP therapy [8,9]. In 2006, Ferguson et al. [10] reviewed the use of MADs in the treatment of OSA and indicated that many patients with OSA can be treated effectively with collaboration and good communication between the dentist and the sleep clinician. Because of this, the role of dentists in sleep disorders is becoming more significant. AASM and the American Academy of Dental Sleep Medicine (AADSM) provide recommendations [11] for the management of OSA using MAD and define the role not only of the physician but also of the dentist in the MAD therapy. In the position paper published in 2012 by Canadian dental sleep medicine professionals [12], the dentistry roles and responsibilities in diagnosis and treatment of OSA are summarized as follows: (1) Recognize the symptoms of sleep-disordered breathing (SDB). (2) As appropriate, refer the patient to a physician with training in sleep medicine.

(3) Assess oral health and the sleep disruption consequences of concomitant bruxism (tooth grinding and/or clenching), gastroesophageal reflux disease (GERD), orofacial pain and/or temporal headache. (4) Manage, within his or her expertise, SDB, sleep bruxism, and the dental consequences of GERD and orofacial pain using the following. (5) Propose various MADs to the patient according to the patient’s oral health status and craniofacial morphology, neurostimulation therapy (e.g., biofeedback) and other appropriate therapies. (6) With a sleep physician, jointly monitor changes in sleep disorders and mental as well as physical health. (7) Monitor the efficacy and safety of the treatment a using valid tool that the dentist can accurately interpret. It is important to emphasize that level III and IV portable monitoring devices (type III and type IV) should be interpreted by physicians according to their diagnostic expertise. A dentist working with PMs should be able to accurately assess the results, which means the dentist will mainly observe changes in respiratory sleep parameters with treatment, but will not diagnose them as a final follow-up. (8) Manage side effects of oral appliance therapy as they develop. The dentist has the important roles during all phase of assessment, therapy, and follow-up of OSA patients using MADs.

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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2.1.

Diagnosis

The most accurate assessment of sleep is via a full-night PSG performed in a sleep laboratory. Unfortunately, PSG laboratories are specialized facilities which are resource-intensive and expensive [13]. Therefore, there is the need for alternative methods to diagnosis, such as portable monitoring (PM), that have been proposed as a substitute for PSG in the diagnostic assessment of OSA. Since OSA is caused by repetitive obstruction of the upper airway during sleep [14] that is created by the effects of muscle relaxation and the tongue falling backward under gravity, the most common methods to detect obstructed breathing events are reduction in airflow measured by a thermistor or a nasal pressure signal, and oxygen desaturation. While there are several PM devices that can do this, the ApneaLink device has been shown to be able to detect OSA and/or hypopnea with acceptable reliability [15].

2.2.

Treatment with a mandibular advancement device

In the practice parameter published by AASM in 2005, MADs are indicated for use in patients with mild to moderate OSA who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. In 2014, Sutherland et al. [16] reviewed the MAD therapy for OSA, and indicated that health outcomes between CPAP and MAD treatments were equivalent, even in severe OSA due to the advancement in technologies related MAD therapy. The reported success rates of the MAD therapy varied among previous studies. One review [10] demonstrated that the patients with mild to severe OSA have a 52% chance of being able to control their OSA using MAD. Another review [17] demonstrated that treatment success with MAD, defined as an AHI of less than 5, was found in 19–75% of the patients and, when success was defined as an AHI of less than 10, the range was 30–94%. The recent review indicated that a complete response (resolution of OSA or an AHI 5% maximum voluntary contraction, MVC) were observed not only in the centric but also in the eccentric, unstable, jaw positions during sleep bruxism (Fig. 2), and concluded that the combination of EMG and jaw movement analysis had potential to study the detailed nature of the sleep bruxism behavior. Although this system was originally developed for detecting and classifying of sleep bruxism, it is possible to obtain continuously jaw movement data during sleep.

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Fig. 2 – An example of jaw movement and masseter muscle activity during sleep bruxism. (A) The upper two tracings show RMS EMG signals of the left and right masseter muscles (Mass), and the three lower tracings show the jaw positions at the incisal point in antero-posterior, left-right, and supero-inferior directions. The baselines in the jaw position represent the intercuspal position. (B) Three dimensional jaw movement trajectories during sleep bruxism. The bold jaw movement trajectories represent jaw positions during sleep bruxism with above 5% MVC. The strong masseter muscle activities are observed not only in the centric but also in the eccentric, unstable, jaw positions during sleep bruxism.

Fig. 3 – An example of hypnogram and jaw positions during a full night’s sleep. The upper tracing shows the sleep stage, and the three lower tracings show the jaw positions in antero-posterior, left-right, and supero-inferior directions. The baselines in the jaw position represent the intercuspal position. A common pattern of jaw movement during sleep was observed in all participants, which was characterized by a gradual opening and a quick closure of the jaw.

Fig. 3 shows an example of hypnogram and jaw positions during a full night’s sleep. A common pattern of jaw movement during sleep was observed in all participants, which was characterized by a gradual opening and a quick closure of the jaw. This finding coincides with Miyamoto’s report [35]. Suzuki et al. [36] recorded jaw movements during sleep in twelve healthy adult subjects without OSA (AHI < 5) using this system, and investigated resting jaw position in the supine position during sleep. The vertical resting jaw opening was calculated every supine position epoch. The mean jaw opening ranged from 2.9 to 6.0 mm. The supine position epoch with greater than 2.5 mm of jaw opening was observed in 84.2% of all supine position epoch. This result is similar to the findings of Miyamoto’s study. They concluded that the vertical

jaw position could be used as a certain reference value to decide the occlusal thickness of splint for treatment of sleep bruxism. The resting jaw position during sleep could be a valuable parameter to determination of the amount of protrusion and bite opening with the MAD. Recently, approach to determination of the centric relation based on analyzing jaw movement in 6DOF while awake was introduced [37]. A functional method for determination of optimum jaw position during sleep in individual patients with MAD is also required. Jaw tracking device in 6DOF can measure the movement of the entire mandible relative to the maxilla. In short, the jaw position and movement of the arbitrary target points, such as the incisor and condylar points, can be estimated. Jaw movement data while awake can help to evaluate the

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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protrusive capacity, the maximum vertical opening, and TMJ disorder in individual patient both before treatment and at follow-up visit. Recording jaw movement during sleep without and with the MAD may play important roles in the evaluation of the jaw posture during apnoeic episodes and of parafunctions such as sleep bruxism and of effectiveness of MADs, and in the determination of the optimum level of jaw protrusion and jaw opening with OSA. The dentist is familiar with the use of jaw tracking devices. The dentist will more certainly play a role in the assessment, therapy, and follow-up of OSA patients using MADs to utilize the jaw movement parameters.

4. Techniques of evaluating airway configuration on cephalometric images In 2008, a review article was published that examined the issue of airway imaging for OSA [38]. Specifically, the authors of this systematic review examined how valuable the various imaging methods of the airway were in the decision making process for evaluating airways. The authors reviewed (1) endoscopy during wakefulness, (2) the value of the Mueller Maneuver, static radiologic imaging techniques (X-ray cephalometry, computed tomography (CT) scanning and magnetic resonance imaging (MRI)), (3) dynamic scanning protocols (e.g. ultrafast CT or cine MRI), (4) upper airway endoscopy during sleep and sedated sleep and (5) pressure measurements and the assessment of the critical closing pressure were included in the review. The authors carefully reviewed each method and concluded that, although these additional techniques for upper airway assessment have substantially improved our understanding of sleep-disordered breathing, their significance in daily practice was limited. The cephalometric image is the most common examination method with standard dental practice in Japan for evaluating the airway. The amount of radiation needed for this image is much less than is needed for a CT type image and the anterior posterior direction is well imaged. Therefore, there are many studies using cephalometric images to reveal the airway in an OSA patient. Cephalometric imaging of an obstructive sleep apnea patient has 3 major problems that are described in most of the previous articles. These problems are: (1) Lateral projection view, (2) Patients’ status: Awake/Asleep, (3) Body and head posture. Although OSA is characterized by the recurrent upper airway obstruction during sleep in the supine position, cephalometric images used to assess airway size in patients with OSA, are generally taken in the erect position, except in experimental situations. In other words, the disadvantage is that the lateral dimension of the airway is not imaged. In addition, the image is universally taken in the upright position, not supine, and the ‘‘collapsibility of the airway during sleep’’ may be difficult to capture. In the previous studies it was reported that the cephalometric measurements correlate only slightly with disease severity [39,40].

4.1.

Change of the airway with body posture

In this section, the influences of body and head posture on the airway are reviewed, and we propose some techniques for evaluating the airway based on previous studies. In 2013,

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Menon and Kumar reviewed the influence of body posture on OSA severity [41]. They concluded that the supine sleep posture is consistently associated with more severe obstructive sleep apnea indices in adults, as compared with the lateral decubitusposition. In 1994, Pae et al. [42] observed the airway on the upright and supine cephalometric images that were obtained from 20 OSA patients and 10 symptom-free control subjects. They reported that the oropharynx was significantly reduced in the supine position as compared with the upright patients with OSA. The airway was reduced an average of 2.4 mm in the upper part of the oropharynx, and an average of 2.2 mm in the lower part of the oropharynx. Furthermore, they concluded that the multiple regression study clearly showed a stronger correlation between RDI and a combination of three upper airway measurements in the supine position than those obtained in the upright cephalograms. In 2002, Battagel et al. [43] analyzed the changes that occurred in the airway and surrounding structures on the cephalometric image when subjects with obstructive sleep apnea moved from the upright to the supine position. They concluded that the antero-posterior dimensions of the oropharyngeal airway decreased highly significantly at all levels, with a concomitant reduction in cross-sectional area. The narrowing was most severe behind the soft palate, where the minimum airway was reduced by approximately 40 percent. Behind the tongue, a 20 percent decrease was recognized. From these results, it is suggested that we have to consider the change of airway due to body posture to evaluate the airway on the upright cephalometric images.

4.2.

Change of the airway with head posture

Fig. 4 shows a cephalometric image of an OSA patient. This patient underwent a PSG examination and was diagnosed with severe OSA (AHI: 40.7 events/h). How do you evaluate this patient’s airway? In various previous studies, it has been reported that the airway was narrowing or obstructed on the cephalometric images of the OSA patients. If we consider the change of airway due to the body posture as mentioned above, it is still hard to determine that the patient’s airway has narrowed. Like this case, the narrowing of airway may not be observed. In 1996, Solow et al. [44] examined the relationship between the diameter of the airway and the posture of the head and cervical column. They reported that the extension of the craniocervical angle and forward inclination of the cervical column were correlated with an increase in the diameters of the three most caudal airways in their OSA sample. The findings were considered to reflect a compensatory physiological postural mechanism that serves to maintain airway adequacy in OSA patients when in the awake erect posture position. Furthermore, the reason it occurred at the lowest levels of the oropharyngeal airway may be due to efficiency issues. In 2002, Muto et al. [45] investigated the relationship between cranio-cervical inclination and pharyngeal airway space by measuring these parameters at different head postures in the same subjects, and calculated a regression model. It became evident that an increase of 4 mm in pharyngeal airway space occurs with a 10 degree increase in the cranio-cervical inclination.

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Fig. 4 – Cephalometric image in a patient with OSA.

In 2011, Zhang et al. [46] observed the airway on MR images in 4 different jaw, head and body positions; 1. supine without protrusion, 2. supine with jaw protrusion, 3. supine with head rotation and jaw protrusion, 4. laterally recumbent position with jaw protrusion. The upper airway exhibited a symmetric shape in the supine position. When head and body position changed, the upper airway was noticeably distorted with an asymmetric shape. However, a significant increase of A-P dimension was induced in the retropalatal region only (2 vs 3, 4). They concluded that head and body positions have little effect on 2- and 3D airway dimensions on supine patients with jaw protrusion.

4.3.

Correction of airway width

¨ zbek et al. [47] investigated for some characteristics In 1998, O of OSA patients that may be related to these adaptive changes in natural head position. Overnight polysomnographic and cephalometric records of 252 adult male subjects with various types of skeletal patterns and dental conditions were examined. They concluded that severe OSA patients may have a greater tendency to exhibit a cranio-cervical extension with a forward head posture. Solow et al. [44] suggested that the increase in the diameters of airway due to extension of the cranio-cervical angle and forward head posture reflects a compensatory physiological postural mechanism for serving to maintain airway adequacy in OSA patients. In 2008, Anegawa et al. [48] investigated the relationship between head posture and pharyngeal airway space (PAS), the cephalometric parameters at different head postures. The mean cranio-cervical inclination (CVT/NSL; cranio-cervical inclination in the second and fourth vertebrae), when the head was in the natural head posture, was 100.9 degrees in normal Japanese males and 103.5 degrees in females. Linear regression analysis revealed PAS (mm) = 0.37 * DCVT/NSL (degree) in

Fig. 5 – Points and lines of reference on the cephalometric image.

males, and DPAS = 0.33 * DCVT/NSL in females. The correlation equations were obtained as follows; the corrected PAS = the actual PAS + 0.37 * [100.9 the actual NSL/CVT] in males, and the corrected PAS = the actual PAS + 0.33[103.5 the actual NSL/CVT] in females. However, there is no report that investigated the relation between OSA severity (AHI) and the corrected airway with the cranio-cervical inclination. For this reason, we investigated the association between NSL/CVT and retroglossal airway space (RGAW) in a series of 60 male OSA subjects. A linear regression model was fitted to the data to predict the retroglossal airway dimensions for a subject with normalized cranio-cervical inclination. The linear relationship between the corrected retroglossal airway [which was calculated with the method same as Anegawa’s study] and OSA severity was then investigated. Subjects were 60 male OSA patients who were diagnosed as snorers or OSA via PSG. Their AHI, age, and BMI were as follows; AHI: 0.2–79.6 events/hour (mean AHI 24.6  17.66), Age: 25–79 years (mean age 51.5  13.56), BMI: 20.1–35.8 kg/m2 (mean BMI 24.8  3.17). The cephalometric image was taken for each patient in natural head posture. Fig. 5 shows points and lines of reference on the cephalometric image. NSL/CVT ranged from 95 to 120 degrees (mean CVT/NSL 109.1  5.97). RGAW ranged from 6.4 to 26.1 mm (mean RGAW 14.6  3.20). There was no significant different between OSA severity and NSL/CVT. This result did not correspond with the above previous study. There was a significant linear relationship between RGAW and NSL/CVT angle (r = .680; p < .001). To predict the RGAW for a given NSL/CVT, we built a linear regression model; RGAW = 0.37 * NSL/CVT 25.3. As a base line of NSL/CVT for normalization of cranio-cervical inclination, 100.9 degrees, which was mean NSL/CVT in Japanese

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Fig. 6 – Relationship between cervical inclination, curvature and airway width.

male, was recruited from Anegawa’s study. The correlation equations were obtained as follows: the corrected RGAW = the actual RGAW + 0.37 * [100.9 the actual NSL/CVT]. The corrected RGAW ranged from 6.7 to 19.1 mm (mean corrected RGAW 11.6  2.35). There was a significant negative correlation between AHI and the corrected RGAW (r = .261; p = .044). Based on these new data, we conclude that in OSA proven Japanese males, there was a significant increase of retroglossal airway width (0.37 mm) for each degree increase in craniocervical inclination. These OSA subjects had cranio-cervical inclination of 8 degrees larger than normal Japanese male patients. In fact, the larger RGAW in OSA patients could be due to an increase in cranio-cervical inclination, a compensatory movement. A method to correct the RGAW for an OSA subject with normal head inclination is suggested. As the corrected airway was significantly correlated with OSA severity, though the correlation was weak, one could consider using this measurement to predict OSA severity based on erect cephalometric images. The authors suggest this retroglossal correction compensates for the fact that patients with OSA change their inclination to breathe better (Fig. 6). In 1989, Hellsing [49] reported a negative correlation between cervical curvature and cranio-cervical inclination. Moreover, he found an interrelationship between change in the lordosis and the cranio-cervical inclination with an increase in the cross-sectional dimension of the lower pharyngeal airway. They concluded that a smaller increase in the lordosis gave a greater increase in the cranio-cervical inclination and in the size of the lower pharyngeal airway. Dobson et al. [50] reported OSA patients exhibit an upper cervical kyphosis. In addition, we also observed the cervical curvature in the above our study. The cervical curvature decreased with increasing of cranio-cervical inclination. From these results, it was suggest that OSA patients have a tendency to change their head posture to increase the airway width which can influence cervical curvature. In a standard clinic, it is difficult to observe the airway in OSA patients during sleep while lying. Therefore, we should pay attention to the influence on airway of the body and head postures while evaluating the airway on the cephalometric images. In addition, cephlometric imaging is used to evaluate the efficacy of Oral appliance (OA). In 1994, Moya et al. [51] analyzed cephalometric images to determine the effect of an occlusal splint on cranio-cervical relationships in subjects with muscle spasms. Cephalometric analysis showed that the

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splint caused a significant extension of the head on the cervical spine and decreases the cervical spine lordosis. In 2009, Inoko and Morita [52] evaluated the changes in the cervical spine associated with the use of OA in patients with OSA. Cephalometric analysis showed that cranio-cervical inclination with OA was higher than those without OA. It seems that the OA caused a significant flexion of the cranium on the upper cervical spine. A significant increase in the cranio-cervical inclination occurred in the fourth cervical segment. They concluded that the changes in forward flexion of the upper cervical spine found in this study imply that changes in the cranio-cervical relationship should be evaluated periodically after an OA has been inserted. From these results, it was considered that there is a strong relationship between the mandibular posture and cervical inclination. Therefore, we should pay attention to the differences of cranio-cervical inclination, when cephalometric images with and without OA are compared.

5.

Conclusion

Based on this review several conclusions are suggested in response to the questions being asked. These questions and answers are listed below: Q1: Should dentists incorporate a sleep breathing disorder screen examination into their work-up of a patient? Answer: Yes, dentists need to screen all patients for significant snoring and obstructive sleep apnea. Q2: What is the best diagnostic strategy to screen dental patients for snoring and obstructive sleep apnea? Answer: In most cases a short sleep apnea risk questionnaire (e.g. modified Berlin or Stop-Bang) will suffice as a screening tool. If the results are suggestive of a sleep breathing problem, the next step is to refer the patient for a more extensive work-up (in-laboratory polysomnography or home testing with portable monitor). Q3: How is an obstructive sleep apnea problem best treated? Answer: There are a variety of methods ranging from CPAP to airway surgery. One good option that the dentist can participate in is the MAD. This device is considered to be a first line treatment for snoring, for mild to moderate OSA and CPAP failures of all severity levels Q4: What is the efficacy of a MAD in the treatment algorithm for SBD? Answer: MADs have a variable success rate ranging from quite low to very high. This variation in success is due to several factors such as (1) the degree of advancement attempted and tolerated by the patient and (2) the criteria used to define success (AHI versus depth of hypoxia criteria). Q5: What is the significance of the relationship between sleep bruxism, GERD and TMD and obstructive sleep apnea? Answer: Because bruxism, GERD, TMD and OSA are all conditions that are co-morbid examining the interrelationships between these disorders in an objective and unbiased fashion is critical. The dental profession needs to keep in mind that because associations exist this does not prove important or clinically relevant causal relationships exist.

Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

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Q6: How do you best monitor mandibular advancement devices for both adverse events and efficacy? Answer: All treatments for a chronic condition have the potential of side effects and adverse events. This is true for a mandibular advancement device and there is ample evidence in the published literature that they can induce TMJ pain, TMJ sounds, myofascial pain, tooth pain as well as occlusal changes due to both tooth movement, skeletal remodeling. For these reasons a careful and periodic follow-up is needed to evaluate the oral structures for these changes. Q7: What is the importance of jaw motion measurements of the masticatory system during sleep. Answer: The true value of jaw motion tracking is yet undetermined. Ongoing studies, like those discussed in this review will clearly help us understand this behavior, but they have yet to show themselves to have clinical significance outside the laboratory. However, this is the nature of basic research the practical implications are not clear at the beginning of most projects. Q9: What is the importance of the shape and form of the airway imaged with a lateral cephalometric radiograph? Answer: Cephalometric films have an ability to show the clinician the anterior-posterior dimension of the airway and they capture how it is changed with mandibular advancement devices and jaw surgery. Like jaw tracking during sleep the practical implications of this imaging modality has yet to be proven. At the very least, the studies described herein can tell us what happens to the airway with alterations in head position, posture and cervical pathology. Time will tell if these investigations prove to be valuable or not in the future.

Conflict of interest No conflicts of interest.

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Please cite this article in press as: Shigemoto S, et al. Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.04.002

Diagnosis and treatment for obstructive sleep apnea: Fundamental and clinical knowledge in obstructive sleep apnea.

This review article covers the diagnosis and treatment of obstructive sleep apnea (OSA) from a dental perspective. It addresses the issue of when and ...
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