Obstructive sleep apnea: a review for the orthodontist

PALOMO, Juan Martin; PICCOLI, Vicente Dias; MENEZES, Luciane Macedo de

doi:10.1590/2177-6709.28.1.e23spe1

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Dental Press Journal of Orthodontics

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SPECIAL ARTICLE • Dental Press J. Orthod. 28 (01) • 2023 • https://doi.org/10.1590/2177-6709.28.1.e23spe1 copy

Obstructive sleep apnea: a review for the orthodontist

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated.

Objective:

Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

Keywords:
Obstructive sleep apnea; Sleep apnea syndromes; Airway obstruction; Orthodontics

OSA risk	Mild	Moderate	Severe
Child	1 ≤ AHI < 5	5 ≤ AHI < 10	AHI ≥ 10
Adult	5 ≤ AHI < 15	15 ≤ AHI < 30	AHI ≥ 30

Questionnaire name and year	Target audience	Number of questions	Type of questions	Assessment
PSQ - 2000 Pediatric Sleep Questionnaire	Children (Age 2 to 18)	22	Yes/No/I don’t know	8 or more Yes answers, or 33% of positive answers when some are left blank or marked “I don’t know” - low or high risk for SDB
ESS-CHAD - 2015 Epworth Sleepiness Scale	Children And Adolescents	8	8 situations to assign scores (0-3)	To assess daytime sleepiness Low sensitivity for AOS
ESS - 1991 Epworth Sleepiness Scale	Adults	8	8 situations to assign scores (0-3)	To assess daytime sleepiness Low sensitivity for AOS
BQ - 1999 Berlin Questionnaire	Adults	10	3 categories	High Risk: if there are 2 or more categories where the score is positive.
NOSE - 2004 Nasal Obstruction Symptom Evaluation Scale	Adults	5	5 conditions to assign scores (0-4)	To assess potential nasal obstruction
STOP-Bang questionnaire - 2008	Adults	8	Yes/No questions + data BMI, age, neck circumference and gender	High sensitivity and specificity to diagnose the adult patient with moderate to severe OSA

EXAM	INDICATION	ADVANTAGE	LIMITATION
Lateral cephalometric radiograph	Provides a 2D evaluation of the profile	Adenoid hypertrophy evaluation	2D representation of a 3D structure. Provides a limited use for UA assessment, as the mediolateral direction in not evaluated
Conventional tomography (CT)	3D evaluation	One of the best imaging modalities for evaluating the nasal cavity and paranasal sinus geometry	High doses of radiation
Cone Beam CT (CBCT)	3D evaluation	Good to evaluate hard tissue structures, good to visualize the airway lumen	No information on muscular tone, susceptibility to collapse or function of the airway. Cannot be used to diagnose OSA alone. There is no direct link between radiographic measures (airway size and volume) with PSG
Magnetic resonance imaging (MRI)	Accurate in measuring the soft tissue lining, fat pad and surrounding structures of the airway in 3D	Good to visualize the airway lumen. No radiation	Metals (fillings and braces) can interfere with the images
Nasoendoscopy	Gold standard for diagnosis of UA obstruction	Direct and functional view of the airway in real time. No radiation	Little opportunity for objective measurement, relies on professional opinion (low interobserver agreement)
Acoustic rhinometry (AR)	Objective method for examining the nasal cavity (evaluates the sound pulse propagation in the nasal cavity by changes in acoustic impedance)	Simple, fast, and noninvasive technique. Clinically useful with very good reliability in the anterior and middle parts of the nasal cavities. No radiation	Reduced accuracy in the posterior part of the nasal cavity
Acoustic pharyngometry	Acoustic reflection technique provides a noninvasive, dynamic assessment of the physiologic behavior, dimensions, and structure of the UA	Useful method to assess OSA. Marketed as a screening method to quickly assess potential sites of UA obstruction and to determine the appropriate treatment. No radiation	Limited accuracy, applicability, and information
Ultrasonography -Ultra sound (US)	Assessment of the UA with no use of ionizing radiation	Simple, fast, and noninvasive technique. Assessment of the UA while in function. No radiation	Evaluation relies on professional knowledge and experience

Treatment options for OSA
Behavioral changes	Weight loss Aerobic exercises Oropharyngeal exercises Alteration in sleep posture Sleep hygiene measures
Medical and dental appliances	Positive air pressure appliances (PAP) Mandibular advancement devices (MAD)
Surgical procedures	Bariatric surgery (for weight loss) Uvulopalatopharyngoplasty Glossoplasty Maxillomandibular advancement Electric stimulation of the hypoglossal nerve

APP OBJECTIVE AND COMMENTS	APP NAME / PLATAFORM (IF SINGLE)	RESEARCH PAPER RELATED TO THE APP	RESEARCH RESULTS
Sleep monitoring Provides users with a graph detailing the level of wakefulness and light/deep sleep	Sleep time	Bhat S, Ferraris A, Gupta D, Mozafarian M, DeBari VA, Gushway-Henry N, et al. Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. J Clin Sleep Med. 2015;11.17.	The app was compared to PSG in adults and found a poor correlation between them concerning the sleep efficiency, light sleep, and deep sleep. No correlation was found between the app and PSG sleep latency with a deficiency in detecting wakefulness. Not effective to awaken individuals during light sleep.
Sleep monitoring Accelerometer-based app designed to ease awakening during light sleep periods.	Sleep cycle	Patel P, Kim JY, Brooks LJ. Accuracy of a smartphone applicationin estimating sleep in children. Sleep Breath. 2017;21:505-11.	App data were compared to sleep analysis with PSG in a clinical population of 25 children (2-14 years) with clinical suspicion of OSA. No significant correlation was found between total sleep time and sleep latency compared to PSG. The authors concluded that the app is not yet accurate enough to be used for clinical purposes.
Sleep monitoring Behavioral training response to auditory stimuli estimates sleep onset.	Sleep on Q (iOS)	Scott H, Lack L, Lovato N. A pilot study of a novel smart-phone application for the estimation of sleep onset. J Sleep Res. 2018;27:90-7	Authors found high correspondence between the app and PSG sleep onset. The app tended to overestimate sleep latency. The authors highlight the potential relevance of use for facilitating power naps in the home environment.
Sleep monitoring Monitors and provides feedback on auditory snore activity.	SnoreLab	Stippig A, Hübers U, Emerich M. Apps in sleep medicine. Sleep Breath. 2015;19:411-7.	Authors tested the ability to distinguish between snoring events and other background noise. Results did not correspond to the concurrent validated ApneaLink Plus screening device, which led authors to conclude that reliability and accuracy are insufficient to replace common diagnostic standards.
Adjunct CPAP monitoring Engagement tool that allows patients to track nightly sleep data and empowers patients to stay engaged and compliant with long-term therapy.	ResMed My Air	Woehrle H, Arzt M, Graml A, Fietze I, Young P, Teschler H, et al. Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database. Sleep Med. 2018;41:20-6	This tool was associated with significant compliance improvement in first-time users receiving CPAP therapy and a significant reduction in air leakage.
Adjunct CPAP monitoring Aims to improve CPAP adherence by a series of text message questions. Patients are asked daily about OSA treatment concerning CPAP use, physical activity, dietary habits, and a weekly recording of bodyweight. Users receive concise recommendations about CPAP use and a healthy lifestyle.	Apnea-Questions (Apnea-Q)	Isetta V, Torres M, González K, Ruiz C, Dalmases M, Embid C,et al. A new mHealth application to support treatment of sleep apnoea patients. J Telemed Telecare. 2017;23:14-8.	Regular users of the app had significantly higher CPAP compliance, with high satisfaction levels for most users.
Orofacial Myofunctional Therapy It is proposed that, by strengthening oropharyngeal muscles by daily exercise, upper airway collapse is avoided.	Airway gym	O’Connor Reina C, Plaza G, Ignacio-Garcia JM, Baptista JardinP, Garcia Iriarte MT, Casado Morente JC, et al. New Health application software based on myofunctional therapy applied to sleep-disordered breathing in non-compliant subjects. SleepSci Pract. 2020;4:1-10	The app provides a permanent record of feedback and accuracy of exercises performed. There was reduction in AHI and in a recent study, authors showed a reduction in AHI and ESS score in 75% of patients using the device after performing daily app exercises for 3 months, compared with a control group.
Orofacial Myofunctional Therapy Users perform 15 minutes of daily voice-activated game play to improve snoring and sleep quality. Users articulate specific phonemes to achieve voice-controlled on-screen objectives.	Snoretech (Android)	Goswami U, Black A, Krohn B, Meyers W, Iber C. Smartphone-based delivery of oropharyngeal exercises for treatment of snoring: a randomized controlled trial. Sleep Breath.2019;23:243-50	Randomized controlled trial with snoring patients showed significant reduction in snoring and ESS after 8-weeks.
Positional obstructive sleep apnea therapy The app aims at position detection (differentiates between prone, back and side positions). Only the preceding night can be displayed	Apnea Sleep Position Trainer	Haas D, Birk R, Maurer JT, Hörmann K, Stuck BA, Sommer JU. Treatment of supine position-related obstructive sleep apnea with smartphone applications. HNO. 2017;65:148-53	Apps were able to prevent positional OSA, being a cost-effective option in the treatment of POSA. Compliance after 6-months was 79.2%.
Positional obstructive sleep apnea therapy In addition to the general functions of position detection and vibration alarm, this app offers a detailed history of position during sleep, of a period.	SomnoPose --- Sleep Position Monitor (iOS)

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[1] luciane.menezes@pucrs.br