Obstructive Sleep Apnea Hypopnea Syndrome OSAHS
INTRODUCTION
A common and underdiagnosed condition, sleep apnea is often linked to a nasal disorder, but also to the morphology of the palate, which prevents air from passing through. Medical management of this condition is carried out by several specialists, including the orthodontist, who plays an important role in screening and treatment.
1- WHAT IS OBSTRUCTIVE SLEEP APNEA SYNDROME (OSA)?
Sleep apnea is a sleep disorder characterized by mild interruptions in breathing during sleep and affects men and women of all ages. The word is derived from the Greek word, apnea, which means “need to breathe.”
The recurrence of episodes of complete (apnea) or incomplete (hypopnea) obstruction of the upper airway during sleep.
2- SCREENING
Screening is often performed by an orthodontist.
Too often, people suffering from sleep apnea are unaware that problems with their jaw are partly the cause. “And yet the jaw plays an important role in the occurrence of sleep apnea: if it is narrow, small, backward and/or if mouth breathing is observed, it is advisable to question the patient about potential pathological signs of sleep and, if necessary, refer them to a specialized facility that can make a diagnosis. These are signs that are not easily identified by other practitioners.”
3- CAUSES OF OSAHS
According to the Canadian Lung Association, obstructive sleep apnea occurs when the upper airway becomes blocked during sleep. Typically, the blockage occurs when the soft tissues at the back of the throat restrict airflow (hypopnea) or collapse and close completely during sleep (apnea). The body realizes that breathing has stopped, and you wake up to take a breath. This cycle repeats several times throughout the night (sometimes 50-100 times per hour) and severely interrupts your sleep. When you wake up, you are drowsy and tired.
4 – CRANIOFACIAL ABNORMALITIES AND RISK FACTORS FOR OSA
4 – 1 – Non-syndromic craniofacial abnormalities
In addition to pathologies that cause thickening of the mucosa of the upper airways, thus reducing the caliber of the ventilation system (obesity with fatty infiltration of the pharyngeal walls), certain anatomical obstacles can be found during the ENT examination.
4 – 1 – 1 – Nasal cavities and nasopharynx
– Anomalies of the nasal septum (scoliosis),
– Hypertrophy of the inferior turbinates;
– Hypertrophy of the adenoid vegetations;
– Pharyngeal tumor.
4 – 1 – 2 – Oral cavity, oropharynx
– hypertrophy of the palatine and lingual tonsils;
– craniofacial anomalies, with midfacial hypoplasia, micrognathia, or retrognathia, which may result in tongue dropping into the oropharynx; reduced coverage, a narrower upper arch and a shorter lower arch than those of control subjects.
– True macroglossia.
The narrowing of the upper airways is of multifactorial origin, with the following main causes in children:
1- Hypertrophy of the lymphoid organs, explaining its peak occurrence between the ages of three and five.
2- Narrowing of the bone structures.
3- A reduction in the caliber of the airways due to infiltration of the pharyngeal walls (obesity, mucopolysaccharidoses, etc.).
4- Abnormalities of neuromuscular control, with a reduction in the tone of the pharyngeal dilator muscles, can also be the cause of OSA or be added to morphological predispositions.
4 – 2 – SYNDROMIC ANOMALIES
Among the syndromic malformations, certain craniofacial anomalies predispose to collapse of the upper airways, requiring early management.
When OSA is severe, surgery or assisted mechanical ventilation is sometimes necessary from the first days of life.
Among the syndromes we cite: Crouzon syndrome, Apert, Pfeiffer and Saethre-Chotzen syndromes (acrocephalosyndactyly type 1, 5 and 3, respectively) In trisone 21 (Down syndrome) are characterized by early synostosis of the cranial sutures which induces hypoplasia of the middle third of the face. The facial skeleton gives an impression of mandibular prognathism by the collapse of the nasomaxillary complex, with the development of class III malocclusions.
5- THE PLACE OF ORTHODONTICS IN THE TREATMENT OF OSAHS
In most children suffering from OSAHS, the primary etiological factor is lymphoid tissue hypertrophy, effectively treated by tonsillectomy and adenoidectomy.
However, Guilleminault et al, based on the files of 400 children with OSAHS studied after removal of the adenoids and palatine tonsils, found persistent sleep-related breathing disorders in 14.5% of cases.
Children who were “non-responders” to surgery in this study had narrow pharyngeal spaces, maxillary underdevelopment and/or mandibular retrosion.
DIAGNOSIS:
Among the elements of the interview and clinical examination, snoring, years described by those around them, daytime sleepiness, obesity, male sex and systemic arterial hypertension (HTA) are suggestive of OSA.
However, the final diagnosis is systematically based on a nocturnal recording. Polysomnography performed in a sleep laboratory is the reference examination for the diagnosis of OSA. It provides complete information on the evolution of the states of vigilance and the quality of sleep of the recorded subject as well as on the quality of their breathing.
TREATMENTS:
CPAP Treatment
Treatment for sleep apnea is most often based on the use of a medical device: continuous positive airway pressure (CPAP). There are also other alternatives and treatments, such as oral appliances and surgery. These options are usually prescribed for minor snoring and mild apnea. Among the non-specific measures for controlling minor apnea, it is suggested to use the technique of positional sleep training and restrict alcohol consumption, as well as sedative medications and weight control.
CPAP (continuous positive airway pressure) delivers a continuous pressure whose level is determined by the sleep specialist. This is the minimum pressure needed to eliminate the obstruction.
THE MANDIBULAR ADVANCEMENT ORTHOSIS: AN ALTERNATIVE TO CPAP
The mandibular advancement splint is a medical device that is placed in the mouth and can only be custom-made based on dental impressions. It keeps the lower jaw in a slightly forward position during sleep, which frees the passage of air in the pharynx and reduces the obstruction that causes so-called obstructive sleep apnea.
It is recognized as an effective treatment for obstructive sleep apnea syndrome (OSAS) in specific cases. It should be noted that the recommendation only applies to custom-made splints. Universal splints – sold in pharmacies or by mail order – are not recommended, as they have not been proven effective in treating sleep apnea.
The orthosis can therefore be prescribed as a “first-line” treatment for mild and moderate apneic patients who do not present major cardiovascular risks or excessive daytime sleepiness. It remains a second-line treatment – but under certain conditions – in the event of failure or refusal of CPAP ventilation for severe apneic patients.
IS A MEDICAL PRESCRIPTION (ORTHODONTIST) REQUIRED TO USE A MANDIBULAR ADVANCEMENT DEVICE?
Sleep apnea is a serious problem that can have serious health consequences. Diagnosis must be made through a sleep test and interpreted by a physician specializing in sleep disorders (pulmonologist or other). Different types of sleep tests can be performed to diagnose sleep-disordered breathing.
A prescription written by a physician or dentist (orthodontist) is required to refer a patient to a laboratory offering sleep testing services (polysomnography, polygraphy).
The physician will determine if a patient is a potential candidate (from a medical perspective) for the use of an advancement device. It will then be up to the dentist to assess whether the patient is a “dental” candidate for wearing such a device.
Although often considered a simple social problem, snoring is often accompanied by sleep apnea. It is therefore also necessary to obtain a diagnosis using a sleep test to ensure that there is no apnea before considering wearing a mandibular advancement device.
6- ORTHODONTIC TREATMENTS IN PEDIATRIC OBSTRUCTIVE SLEEP APNEA SYNDROME While surgical
removal of adenoids and tonsils is the first line of treatment, some patients may experience persistent ventilatory disturbances after surgery or recurrence of symptoms a few years later. Certain maxillofacial characteristics have been associated with these surgical failures and also constitute risk factors for OSA, found in a third of children treated: maxillary underdevelopment with a narrow and ogival palate, mandibular retrosion or hyperdivergence. The aim of this course is to describe the role and practical modalities of early orthodontic treatments, including two orthopedic devices that have shown effectiveness in pediatric OSA: mandibular propulsion orthoses (activators, Herbst rods, etc.) and rapid maxillary disjunction.
Obstructive Sleep Apnea Hypopnea Syndrome OSAHS
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