'satisfactory smile' with a restorative approach - Indian Dental ...

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IMAGE 2010-11 ISSN: 2229-5658 Vol No: 11 ISSUE No: 4 17 reduced airflow to the lungs, producing hypoxemia that eventually causes the patient to arouse enough to resume breathing. This arousal is an interruption in the patientís sleep, though often not severe enough to completely awaken the patient. Severe apnea patients experience up to 1- minute apnea, producing a significant hypoxemia before arousal occurs. They may exhibit repeated sleep/arousal cycles throughout the night. Hypoxia resulting from apnea may lead to severe medical conditions that include bradycardia, tachycardia, systemic hypertension, pulmonary hypertension, acute pulmonary edema, reversible highgrade proteinuria, and possibly sudden infant death syndrome. This lack of sleep and the poor quality of sleep cause common symptoms such as hypertension, excessive daytime sleepiness, cognitive dysfunction, memory and judgment impairment, irritability, decreased libido, nocturia, sweating, fatigue, headaches, depression, and an increased tendency for accidents. Children with sleep apnea may exhibit poor school performance and hyperactivity. Diagnosis Although the dentist is a part of the treatment team, the dentist does not diagnose or determine treatment for sleep apnea patients. However, dentists must be able to identify potential apnea patients, refer them to a physician for definitive diagnoses and treatment planning, and serve as a part of the treatment team. After a preliminary examination the physician may refer the patient for an overnight polysomnography study in a sleep clinic. The polysomnogram (PSG) is used to evaluate the sleep and breathing patterns. The PSG can determine the existence, type (central, obstructive or mixed), and severity of any apnea disorders. The PSG is also used to later determine the effectiveness of any completed treatment. If the PSG reveals the existence of a sleep apnea, further diagnostic tests, such as a complete blood count and thyroid function, may be helpful in evaluating these patients. If an upper airway obstruction is diagnosed, other studies such as ENT examinations and radiographs may be required to determine the cause of the obstruction. The patientís respiratory muscles making no effort to breathe characterizes central apnea. Obstructive apnea is characterized by the respiratory muscles making an attempt to breath but the airflow is either blocked or severely limited because of some obstruction in the upper airway. Mixed apnea is a combination of central and obstructive apneas. The common sleep apnea patient is a middle-aged to older, obese, male, smoker, who uses alcohol and/or sedatives and who snores loudly. However, any patient complaining of snoring or excessive daytime somnolence should be considered a potential sleep apnea patient. Treating OSA Patients The ideal results of treating OSA patients would be increased life expectancy, decreased health hazards, and improved quality of life. Because of the potentially ìlife-threateningî severity of apnea, diagnosis and selection of the proper course of treatment, which may include behavioral modification, surgical intervention, nasal continuous positive air pressure (NCPAP), medication, and/or removable dental prostheses, are vital. Behavioral Changes Behavioral changes, which may include weight loss, changing sleep positions, head posture, quitting smoking, and avoidance of central nervous system depressors, may be beneficial for some patients. Visit: http://image.idakunnamkulam.com/ The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM 8, 9 Surgical Intervention The following surgical procedures have been suggested for the treatment of OSA: tracheostomy, mandibular surgery, nasal septal surgery, hyoid bone suspension, partial tongue resection, maxillomandibular advancement osteotomy, inferior mandibular osteotomy, lingualplasty, genioglossal advancement with hyoid myotomy and suspension, and uvulopalatopharyngoplasty. 10 Tonsillectomy and adenoidectomy may be indicated for children with OSA caused by adenotonsillar
IMAGE 2010-11 ISSN: 2229-5658 Vol No: 11 ISSUE No: 4 18 hypertrophy. Tracheostomy is successful because it provides an airway below the obstruction; however, because of negative psychological and esthetic effects, its indication is limited. The use of palatoplasties has produced contrasting results. Maxillary and mandibular osteotomies are recommended for patients with severe OSA, morbid obesity, and severe mandibular deficiency. A two-phase surgical procedure, genioglossal advancement with hyoid myotomy and suspension and uvulopalatopharyngoplasty has been shown to be effective in 60% or more of patients with OSA, which compares very favorably with NCPAP. Nasal Continuous Positive Airway Pressure (NCPAP) NCPAP is a method of providing room air under pressure to patients by using a small air pump connected to either a sealed face or nose mask. The technique appears to work by splinting the pharyngeal airway open and preventing the soft tissues from collapsing and blocking the airway. 11 Although NCPAP has been shown to be successful in 62% of OSA patients, patient compliance is poor because of mask discomfort, pump noise, dryness, and portability problems. Medications and Dental Devices There are many published studies that describe the use of medications for treating sleep apnea. However, few studies have reported positive benefits and none have been shown to be significantly effective. Dental devices used most often include the tongue retaining device (TRD) and mandibular advancement appliances (MAAs) (Figs. 3 through 5). With the TRD the tongue is prevented from dropping posteriorly by suction created when the patient forces the tongue into a hollow bulb built into the device. Patients can maintain the tongue in the bulb for several hours per night, often all night long, once they are accustomed to wearing the device. An advantage of this device over the MAAs is that it can be used for edentulous patients. 12 In counteracting fluctuating genioglossus muscle activity, they also block the oral airway and therefore any compromise of the nasal passage must be surgically corrected. Rationale for the Use of Mandibular Advancement Appliances It is postulated that the principal mechanism of action of these appliances is: Anatomical: which include increased upper airway calibre and decreased upper airway compliance. 13 Thus, forward and inferior displacement of the mandible not only acts to increase the size of the pharyngeal airway by drawing the tongue forward through its muscular attachments, but preserves the velopharyngeal airway by stretching the palatoglossal and palatopharyngeal arch, thereby reducing airway collapsibility of the airway. Physiological: There is some evidence relating to the effect of MAA on upper airway dilatory muscle activity, which may serve to compensate for the reduction in tone, observed during sleep disordered breathing. 14 Design Features There is considerable variation in the design of MAA, but all posture the mandible forwards, to a varying extent, with a degree of vertical opening. They may be prefabricated or custom-made using a soft or hard plastic and as a one- or two-piece design. This is not appropriate in subjects with epilepsy, as it could potentially obstruct the airway if it were to become dislodged during a nocturnal seizure. The currently available appliances could be broadly classified in to three types, based on a succession of design modifications, which importantly permit incremental advancement of the mandible. First Generation These were primarily one-piece in design, with no ability to advance the mandible incrementally without a new appliance being fabricated (Figure 3). Visit: http://image.idakunnamkulam.com/ The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM
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