Significance of Epworth Sleepiness Score

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Significance of Epworth Sleepiness Score

• Not diagnostic - only an indication of potential
  for having OSA
• You may or may not have OSA and it may be mild to
  severe no matter the score
• 0 - 10 OSA not likely
• 11 - 15 Mild to moderate OSA possible
• 16 - above Severe OSA possible

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Preliminary Diagnosis

• Snoring only
• Snoring and potential upper airway sleep disorder
  
• Definite disorder OSA or UARS

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Oral Devices for TreatingSnoring and
Obstructive Sleep Apnea
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Oral Devices Indications

• Recommended for snoring and mild to moderate
  sleep apnea if CPAP unsuccessful.
• Practice parameters for the treatment of snoring
  and obstructive sleep apnea with oral devices.
  An American Sleep Disorders Association Report.
  Sleep. 199518(6)511-13

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Problems with MADs after long term use (3 years
or more)

• Minor jaw/facial, tooth, muscle pain 40
• Xerstomia 30
• Very Satisfied 82
• Satisfied 15
• Painless but irreversible change in occlusion -
  26

GT, Sohn JW, Hong CN. Treating obstructive sleep
apnea and snoring assessment of an anterior
mandibular positioning device. J Am Dent Assoc.
2000131765-71.
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CLINICAL IMPLICATIONS

• Patients with mild-to-moderate OSA who receive a
  two-piece, adjustable MAD should be informed that
  50 percent of patients quit using the device in a
  three-year period and some will experience shifts
  in their occlusion.

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Good Candidates

• Younger age
• Lower BMI
• Lower AHI
• gt8 mm mandibular protrusion but more side effects
• Neck size lt17 F or lt20 M
• Class II occlusion
• Mild to moderate SDB

Dr. Kathleen Ferguson, MD / Dr. Sheri Katz, DDS
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Poor Candidates

• Morbid Obesity
• Obesity-Hypoventilation
• Severe OSA
• Significant Hypoxia
• Severe Sleepiness
• Class III occlusion
• Less than 6 8 mm protrusive capacity

Dr. Kathleen Ferguson, MD / Dr. Sheri Katz, DDS
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Device Treatment Options

• Tongue Retaining Device (TRD)
• Mandibular Advancement Device (MAD)

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Tongue Retaining Device(TRD)

• Laboratory fee - 150

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TRD Findings

• Altered the timing of the inspiratory
  genioglossus (GG) activity and the onset of
  inspiration effort
• Oxygen desaturation index dropped to fewer than
  10 events/ h in 75 of patients
• Significantly improved the blood oxygen
  saturation level in infants
• Helped patients with mild to moderate OSA
  however, patients with more severe OSA may also
  be treated effectively

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Indications for TRDs

• Edentulous patients
• Patients with potential temporomandibular joint
  problems

Problems with TRDs

• Sore tongue
• Tongue elongation

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Tongue Retaining Device
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Kelgauge
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Mandibular Advancement Devices

• Fixed - 100 - 500
• Adjustable - 300 - 800

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Fabrication of an Adjustable Laboratory
Fabricated Device
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Adjustable MADs

• Mx / md diagnostic casts
• 75 protrusive record
• Indicate existing fixed restorations and
  periodontal status of patient
• Minimal insertion time
• Patient adjusts device as needed until snoring
  stops and no discomfort

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Practice CR to maximum protruded position
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Patient closing in the pre-selected
protruded position
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An interocclusal recording is made using the
wax matrix
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Adjustment of the device must be made depending
on device fabricated
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Patient instructions for adjustment(depends on
device but typical)

• No adjust for first 3 nights to allow patient to
  become accustom to device
• Protrude device 0.25 mm per night for 3 4
  nights, stop, check for improvement
• Protrude device 0.25 mm per night for 3 4
  nights, stop, check for improvement
• Continue until symptoms are relieved or reduced
  or TMJ symptoms develop

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Evaluation

• Following relief of symptoms allow patient to
  wear device for 2 4 weeks
• Have patient wear a Pulse Oximetry device and
  determine success of treatment
• Continue adjustments and followup Pulse Oximetry
  or
• Refer to Physician for reevaluation (2nd
  polysomnography)

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Medical-legal Considerations

• Device may initiate TMJ problems
• Permanent tooth movement
• Loss of posterior occlusion overnight
• Potential loosened fixed restorations
• OSA may become more severe with oral devices!
• OSA may be Life Threatening!!!!!!
• You must use a Consent Form

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Patient Should Expect

• Lips will be very dry - lip balm
• Difficulty going to sleep for a few nights
• Lots of saliva - on pillow
• Teeth may become sensitive - seek care
  immediately - usually slight adjustment

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Patient Should Expect

• For approximately 20 minutes upon awakening teeth
  will not close together - dont force closure -
  no treatment
• TMJ discomfort - May be sore for a few minutes
  during early adjustment, must be relieved by
  moving mandible posteriorly

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Is Insurance Coverage Available? Yes and No

• Yes - medical insurance coverage is possible for
  treatment of a sleep apnea problem
• No - medical insurance coverage for a snoring
  only problem
• No - dental insurance coverage for either

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Treating OSA with Oral Devices
MD exam 100 500 Initial Sleep Study 900
1800 Device and Follow-up 800 2000 Pulse
Oximetry 35 200 Repeat Sleep Study 900
1800 Total 2735 6300
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Consent Form Before Treating

• Device for treatment of snoring and/or OSA
• May cause existing dental restorations to
  loosened or fail
• Epworth sleepiness score and significance - ie
  low score doesnt eliminate OSA

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Consent Form Before Treating

• Cease wearing and return to dentist immediately
  if any problems develop - TMJ, occlusal changes,
  etc
• Device may only be partially successful
• Device may increase severity of an existing OSA

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