Sleep Apnea Syndromes

Introduction
As you know nowadays there is a big interaction between dentistry and sleep positions to a point that now there is a specialty known as dental sleep medicine derived for the issue with an academy for it in the U.S. known as the American academy of sleep medicine. Currently Im involved in a research with two of your master degree colleagues regarding the matter. Attention is needed here as patients who are represented with sleep apnea syndromes especially those who have obstructive sleep apnea, you as a dentist would be the first one to notice it and send him to a sleep evaluation.

How much sleep and what is adequate?

Now we all know that we approximately sleep about 1/3 of the daily 24hours which is on average about 8hours. Some people sleep more or less but for sleep to be refreshing or restorative i.e. adequate you need not only an adequate time of sleep but also an adequate depth and continuity of sleep (continuity means in one go and not fragmented also known as consolidated sleep).

Stages of sleep
Earlier adequate depth of sleep was mention and that meant we go through our sleeping process in stages. We have two generalized kinds of sleep the non-REM sleep and the REM sleep with REM standing for Rapid Eye Movement. In neurophysiology REM is known as an incense mental activity but complete muscle paralysis. Some researchers allocate it as being stage5 but it is commonly referred to as REM sleep Non-REM however is when the brain is resting but the patient is capable of moving and it is further subdivided into
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o Light sleep Stage 1: 1-2.5% Stage 2: 45-55% o Deep sleep ( sleep) Stage 3: 3-8% Stage 4: 10-15% stages 3 and 4

although there isnt that much of a difference between

This histogram illustrates how we enter sleep and as you can see we travel from one stage into another. The blue bars represent the REM and during our movement between stages you can see the length of the REM increases as the night time gets closer to end i.e. at dawn/fajir and that is if you notice when most of your dreams occur; you dream immediately before waking up. There is a transition between wakefulness and sleep that is usually smooth which you arent able to feel. You can never pin point the exact moment you transitioned into sleep in unless you undergo a sleep study

Internal Medicine |Sleep Apnea Syndromes

Sleep Studies
We call a sleep study a polysomnogram PSG and it is done over the entirety of a night (all night) in which we usually need the patient to sleep about 8 hours to score 1 record. Most people are not able to sleep for the entire 8 hours due to different reasons like not being comfortable using the pillow in the lab or the bed so sometimes half the wanted period of sleep is acceptable. When they have severe sleep deprivation is when they are able to sleep for the entire time. When we record a sleep study we divide up the inputs into 30sec intervals and we call these intervals epochs. The values we study from the polysomnography include EEG for the study of brain waves, EOG for the study of eye movements thereby deciding whether it is a rapid eye movement REM or a slow eye movement, EMG which is either submental (on the chin) or on lower muscles (shoulders) as other sleep disorders can be associated with movement during sleep, EKG for the tracing of heart waves to record occurrences such as cardiac arrhythmias, measuring the oral and nasal airflow in which we could determine if the patient has an apnea or hypopnea, chest and abdominal respiratory effort through reading their movements to know whether it is an obstructive or a central disorder There are other things that we could include such as video monitoring and sound recording the patient in the sleep lab to record behaviors and snoring. And these are the basics of the polysomnogram.

Internal Medicine |Sleep Apnea Syndromes

Apnea and Hypopnea

Apnea is defined as the cessation of breathing airflow i.e. when you measure the airflow there is no tidal movement as in a straight line which lasts greater than 10 seconds.
No waves > 10sec

Hypopnea is defined as an incomplete cessation of breathing airflow causing a decrease in the amplitude of the wave by 50%. If its more than 50% then it is associated with a reduction of oxygenation.

Now if I conduct a study on all of us in this hall I can find about 5-10% of us having a sleep apnea syndrome however the remaining 90-95% might have up to 5 apneas or a hypopneas during sleep which is at a normal rate but if the incidents exceed 5 times then the person is considered to have a sleep apnea syndrome and there are three types of sleep apnea syndromes: Obstructive apnea: here the problem is centered on the upper airway i.e. cessation of airflow at the nose and mouth with no problems arising from the CNS and chest and respiratory muscles are moving. OSA is a separate entity and has different etiologies and must be treated specifically.
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 Central apnea: here the problem arises from the CNS where there is no respiratory effort in addition to the cessation of airflow i.e. nose and mouth obstructed and no movement in chest and abdomen therefore no tidal waves in the readings at all. In most cases this type of apnea can be associated with medical disorders such as strokes and heart failure and it often does not have a specific treatment. If possible we can only treat the disease that caused it but not treat the central apnea itself. Mixed apnea: here the apnea may start as obstructive and continue as central or viseversa.

In the past we used to have to ask the patient to sleep while an MRI is being conducted in order to see and prove an existing case of OSA but with the new advancements of the polysomnography we no longer need that technique. Also dude to the loud nature of an MRI machine the patient couldnt quite sleep through such noise therefore the entire process was an obsolete investigation.

Apnea Hypopnea Index (AHI)

When we study patients the values we note are called scores and this scoring is to count the number of apnea and hypopnea event. For example a patient who slept for 6 hours had 360 apneas and hypopneas (we add the apneas and hypopneas scored together) recorded. We divide the recorded scoring by the number of hours slept scaling of the events is as fallows Normal: less than 5 events per hour Mild: 5-15 events per hour
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events per hour. Now the

 Moderate: 16-30 events per hour Moderately severe: 31-39 events per hour Severe: over 40 events per hour (believe it or not Ive seen cases with a 120 AHI)

Pathogenesis
The pathogenesis of the apnea-hypopnea is not yet clear as there are many theories such as functional abnormalities in the pharyngeal muscles which are augmented by the presence of some anatomic abnormality. Sometimes the sole pathogenetic mechanism is the presence of an anatomical abnormality and the biggest example is the obstructive sleep apnea OSA in children caused by tonsilar enlargement. So other examples regarding anatomical abnormalities/complications of OSA include nasal problems like Obesity being the biggest contributor chronic rhinitis with hypertrophy of the nasal mucosa nasal septum deviation nasal masses nasopharyngeal masses nasal polyps tonsilar and adenoid hypertrophy hypertrophy of congenitally low palate and uvula facial malformations chromosomal abnormalities such as down syndrome endocrine disorders such as hypothyroidism and acromegaly neurological and neuromuscular disorders such as post-poliomyelitis and muscledystrophy

All these are examples of diseases of distorted craniofacial anatomy that may cause an airway obstruction.

Internal Medicine |Sleep Apnea Syndromes

Symptoms of OSA in adults

A referral by a smart dentist is probably the most effective way for diagnosis because dentists receive all their patients open mouthed and most of the clues leading to OSA are seen in the oral cavity such as an enlarged uvula, a lowered palate, large tongue, large teeth, distorted teeth or micrognathia. Other symptoms include excessive day time sleepiness, snoring and witness apnea which is mostly alarming for a spouse as they witness the patient as theyve stopped breathing Finally non-specific symptoms include Restless sleep High blood pressure Morning headache Dry mouth upon awakening Depression Severe Anxiety Short term memory loss Intellectual deterioration Temperamental behavior Poor job performance Impotence To the right are all examples of a massive uvula, massive tonsils and a massive tongue that are all indications to an obstructive sleep apnea.

Internal Medicine |Sleep Apnea Syndromes

Above is whats known as the mallampati score which is used for OSA evaluation where the patients oral cavity is examined to see the rate of visibility of the tonsil, hard and soft palate and accordingly placed into one of 4 classes. A contributing factor to OSA is the neck size and BMI as the neck size is not only related to obesity as some patients with a normal BMI might have a thick neck which makes them exposed to OSA. If the neck size is over 16 inches and or the BMI is over 25 the person may at risk for an OSA. The reason were interested in studying OSA is because it contributes to mortality. To the left is a study conducted comparing mortality to apnea-hypopnea index and the fount that patients with an AHI above 20 have a higher mortality rate than those with a AHI lower than 20. The mortality usually occurs from cardiovascular events both heart and brain and traffic accidents as the driver can fall asleep causing an accident.

Internal Medicine |Sleep Apnea Syndromes

Further explanations
What happens during sleep is that the entire body muscle system relaxes including the pharyngeal muscles so the opening of the pharynx reduces which is adequate for oxygenation as were not moving and dont need large amounts of oxygen. In OSA patients however they have an excessive narrowing of the pharynx to the degree which causes the snoring which progresses to the complete closure of the upper airway which is the apnea itself. At this point the brain goes through a phenomenon known as an arousal which is sort of an alarming in the brain to send orders to the muscles to contract again upon which the muscles contract and the pharyngeal muscles contract resolving the apnea. This arousal is repetitive and with every arousal of the brain many systems in the body are stimulated such as the sympathetic system, the coagulated system, inflammatory pathways, metabolic deregulation and many, many more metabolic pathways are stimulated which eventually leads to hypertension and ultimately both systemic and diastolic heart failure and many other cardiovascular events that lead to death.

Internal Medicine |Sleep Apnea Syndromes

Treatment Modalities of OSA

Non-surgical treatment o Weight loss: a large amount of patients successfully reduce their AHI upon losing weight. If the patient cannot lose weight through diet and exercise then studies have shown that a gastric bypass surgery is helpful in both reducing the BMI and AHI

o nCPAP: it is the gold standard treatment for OSA for patients who can tolerate the procedure. It forms a pneumatic splint to the airway i.e. pushes through controlled air pressure that keeps the airway open as if its an air cast for the airway. The amount of pressure used is titrated in the lab so once we have the polysomnogram proving an OSA we readmit the patient into the sleep lab and apply the nCPAP and keep increasing the pressure until the polysomnogram comes out clean of an OSA reading. There are types of masks facial, oral or nasal depending on what the patient can tolerate. Some side effects include the fact that the patient has to exhale against the pressure provided by the machine. This helps in severe sleep apnea.

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o Positional changes: during the polysomnogram taking there are sensors that let us know the position of the patient i.e. is he supine, lateral left or right and so on. If the OSA was recorded while the patient was supine then wed advice the patient to avoid sleeping in that position and as the movement during sleep is involuntary some tricks such as for patients who shave shown OSA in supine position to have a tennis ball placed in the back of their pajamas so that if they turn on their backs they would feel irritated and move to their side. As this is transitional it helps in mild and moderate sleep apneas. o Orthodontic appliances: these are used in cases of moderate to severe sleep apnea such as the equalizer, tongue retainers, mandibular advancing and mandibular repositioning appliances.

Surgical treatments o Uvulopalatopharygoplasty (UPPP) o Tracheotomy o Mandibular Advancement o Hyoid bone suspension o Tonsillectomy & adenoidectomy o Thyroidectomy o Nasal septum deviation repair One of the most important things that you must keep an eye on especially as a dentist is if you suspect an OSA after taking the patient medical history that included clues such as snoring, excessive day time sleepiness, fat neck and so on you must warn him of using CNS depressants and alcohol within 4 to 6 hours of sleep and that he must warn the doctors if he is to have any operation as he is not allowed to be under any anesthetic as these elements will prevent the brain from having arousals when its supposed to thereby killing the patient.

Done by: Mohamed Harun Sanoh

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