OFP Sleep

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OFP Sleep
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2014-06-10 14:06:06
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OFP sleep
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  1. RDI (Respiratory disturbance index)
    • avg # respiratory disturbances (obstructive apneas, hypopneas, and respiratory event–related arousals [RERAs]) per hour.
    • RDI=AHI+RERA
  2. AHI (Apnea Hypopnea Index) (cut scores for classification of severity)
    • # disordered breathing events/ hour.
    • measure the severity of sleep apnea as a combination of sleep apnea and hypopnea.
    • 5–15/hr = mild
    • 15–30/hr = moderate
    • > 30/h = severe.
    • #apnic + hypopneic events per hr
  3. UARS (Upper airway resistance syndrome)
    • airway resistance to breathing during sleep.
    • primary symptoms: excessive daytime sleepiness (EDS) and excessive fatigue.
  4. Respiratory effort-related arousal (RERA)
    arousals from sleep that do not technically meet the definitions of apneas or hypopneas, but do disrupt sleep.
  5. O2 saturation (normal vs sleep breathing disorder ranges)
    • 96%+ normal
    • sleep breathing disorder can get down to ~70%
  6. What is considered a normal sleep cycle. How does it changes during the night?
    • Normal sleep cycle consists of Non-REM and REM sleep.
    • Non-REM is divided into 3 stages; stage 1 (2-5%) and 2 (40-55%) are the lightest sleep. And stage 3 has a slow delta wave; magic sleep (25%). REM which has rapid eye movement, dream sleep and forms 25% [50% in infants] of the TST. hypotonicity/paralysis; 90 minute cycles
  7. Is a sleep lab split study in which the patient is awakened and a CPAP machine placed on the patient for the second half of their night’s sleep always representative or can it be suspect?
    SUSPECT-If testing, make sure to sleep for TWO night; the first night, they prob wont sleep their normal sleep;
  8. What is the value of a single night sleep lab PSG study compared to a 2-3 night study?
    • If testing, make sure to sleep for TWO night; the first night, they prob wont sleep their normal sleep;
    • However it is much more costly to do a 2-3 night study; so mostly doing 1 night or even ½ night.
  9. What breathing machines are the alternative versions to a CPAP breathing machine technology?
    • A BiPAP (bi-level positive airway pressure) machine works in a similar way to CPAP but it allows air to be delivered at two alternating levels. Commonly used to treat central sleep apnea, BiPAP allows for easier exhaling making it also suitable treatment for patients with heart and respiratory problems. VPAP devices are even more sophisticated enabling a variable airflow which can react to spontaneous breathing episodes.
    • An AutoPAP differs from a CPAP in that an AutoPAP uses algorithms to sense subtle changes in the user's breathing and deliver only the amount of pressure necessary to keep the airway open.
    • An AutoPAP automatically varies the pressure to prevent and/or correct sleep disordered breathing events - apneas, hypopneas, air flow restrictions, and snores.
    • C-flex: C-Flex pressure relief technology makes sleep therapy more comfortable by reducing pressure at the beginning of exhalation and returning to therapeutic pressure just before inhalation.
    • other options: oat; mandibular advancement device, tongue repositioning, weight loss, body positioning, etc
    • combination therapy
  10. Sleep latency (what is a normal range; what is the implication of falling asleep in seconds; what is sleep induction insomnia)
    • sleep onset latency (SOL) is the length of time that it takes to accomplish the transition from full wakefulness to sleep, normally to the lightest of the non-REM sleep stages
    • 0-5 minutes: severe sleepiness
    • 5-10 minutes: troublesome
    • 10-15 min: managable
    • 15-20: excellent
  11. sleep induction insomnia:
    inability to fall asleep;
  12. Sleep-onset insomnia
    difficulty falling asleep at the beginning of the night, often a symptom of anxiety disorders
  13. What is the difference between insomnia reported as problems in Sleep Induction, and in Sleep Disturbance ?
    • difficulty in falling asleep or difficulty in staying asleep throughout the night; frequent awakening
    • episodic , short term (3 weeks) or long term
  14. How should you react to report of any snoring in an infant or child?
    • SNORING IN A CHILD IS NOT NORMAL!
    • Children get neurocognitive damage-act like ADHD/ agitated and hyperactive when they are sleep deprived; get brain damage too
    • seek advice of sleep specialist
  15. What are the cut scores for measurement of the neck circumference in females and males that enter in predictive index measurements for sleep apnea?
    • 16in female
    • 17in male
  16. Does this mean that if you see a patient with a slender neck that they do not have obstructive sleep apnea?
    NO!
  17. Is it true that individuals can have many sleep microarousals without fully waking up or being aware of these arousals?
    Yes
  18. What medical problems or diagnoses can wake a patient up from their sleep?
    • Hypoxia, hypercapnia, acidosis and pulmonary hypertension (as it causes shortness of breath)
    • diabetes, GERD, hypertension, mental issues; arthritis;/chronic pain
  19. What medical and sleep issues or diagnoses can account for headache on waking, and must be considered in the differential, rather than the over attribution of headache to sleep bruxism in patients with observed occlusal attrition?
    analgesic rebound, sleep apnea, migraine, anxiety/psychologic issues, musculoskeletal (neck pain)
  20. (SDB): Sleep-Disordered breathing
    SDB: Sleep-disordered breathing is a group of disorders characterized by breathing difficulties while sleeping It is a more globalterm that includes SRBD, upper airway resistance syndrome (UARS), and snoring,OSA making SDB the most prevalent sleep disorder group.OSA is the most common of these
  21. Bruxism is considered a micro-arousal phenomenon: so in which stages of sleep does it mostly occur?
    • light sleep-stage 1 and 2
    • rarely in REM
  22. Does sleep bruxism ever occur during REM?
    rarely
  23. What type of commonly prescribed antidepressants can cause or worsen sleep bruxism events?
    Bruxism may be linked to a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI). Examples of SSRIs include paroxetine, fluoxetine and setraline.
  24. Is tooth contact the first system event to occur in a sleep bruxism episode?
    No, it begins with sympathetic/ parasympathetic balance, preceding jaw opening & clenching events
  25. What is meant by “discussing sleep hygiene” with a sleep disorder patient?
    Sleep hygiene is the controlling of "all behavioural and environmental factors that precede sleep and may interfere with sleep following guidelines in an attempt to ensure more restful, effective sleep which can promote daytime alertness and help treat or avoid[2] specific kinds of sleep disorders.
  26. What is the problem of prescribing sleep medication/hypnotics with sedation side effects to a patient with obstructive sleep apnea ?
    Sedatives, narcotics, antidepressants, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers.
  27. What is meant by the collapse of the oropharynx during sleep and when is this most likely to occur?
    • loss of muscle tone in oropharynx
    • intraluminal pressure is 0
    • deficiency of upper airway dilator muscles.
    • During REM sleep in particular, muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea, to impede the flow of air to a degree ranging from light snoring to complete collapse.
  28. Is there perhaps a positive benefit to sleep bruxism episodes in an individual with obstructive sleep apnea ?
    • Bruxic appliance makes sleep apnea worse, maybe because it is occupying part of the space.
    • Periodically tonic activity going on to get away of the collapsibility of the area of breathing.
  29. How much (mm) do you need to be able to bring the jaw forward (protrusion) to use a mandibular repositioning/advancement appliance to treat obstructive sleep apnea?
    • 75% of maximum physiologic protrusion (50-90%) ???. It is variable depending on the appliance a lot of the time they use 60% of the maximum mandibular protrusion with 2 mm ofc vertical speration (http://www.journalsleep.org/articles/250504.pdf)
    • 5mm minumum protrusive capacity?
    • he said 8-9 mm in class
  30. What type of sleep apnea can you treat with a mandibular advancement appliance; what severity can you treat?
    • Obstructive
    • Airflow is blocked.
    • Air cannot enter lungs.
    • Site:Airway
    • Causes: Weight (adults), Tonsils (children), Jaw anatomy.
    • Central
    • The drive to breathe is reduced.
    • Site:Brain
    • Major Causes:Heart failure.
    • OBSTRUCTIVE! Mild to moderate severity.
    • Central apnea there is no movement at all.
  31. What is a Circadian Rhythm Shift and how does this contribute to sleep problems and daytime
    • sleepiness?
    • Circadian rhythm sleep disorders (CRSD) are a family of sleep disorders affecting, among other things, the timing of sleep. People with circadian rhythm sleep disorders are unable to sleep and wake at the times required for normal work, school, and social needs. (teenagers; shift workers, etc)
    • Ciracidum Rhythm is any biological process that displays an endogenous, entrainable oscillation of about 24 hours.
  32. Does pulling an all-nighter to study for an exam affect memory and recall.
    MEMORY
  33. Sleep efficiency
    Sleep efficiency: the number of minutes of sleep divided by the number of minutes in bed. Normal is approximately 85 to 90% or higher.-decreases w age
  34. REM sleep behavior disorder
    • Rapid eye movement sleep behavior disorder (RBD) is a sleep disorder (more specifically a parasomnia) that involves abnormal behaviour during the sleep phase with rapid eye movement (REM) sleep. It was first described in 1986.
    • This extends from simple limb twitches to more complex integrated movement, in which sufferers appear to be unconsciously acting out their dreams. These behaviours can be violent in nature and in some cases will result in injury to either the patient or their bed partner.
  35. CPAP (Continuous positive airway pressure)
    • Continuous positive airway pressure (CPAP) is the use of continuous positive pressure to maintain a continuous level of positive airway pressure in a spontaneously breathing patient
    • maintain upper airway patency; prevent collapse.
  36. Excessive daytime sleepiness (EDS)
    • Excessive daytime sleepiness (EDS) is characterized by persistent sleepiness and often a general lack of energy, even after apparently adequate or even prolonged night time sleep. EDS can be considered as a broad condition encompassing several sleep disorders where increased sleep is a symptom, or as a symptom of another underlying disorder like narcolepsy, sleep apnoea or a circadian rhythm disorder.
    • 20% of MVA associated w EDS
  37. Epworth Sleepiness Scale (ESS)
    • measure daytime sleepiness
    • short questionnaire
    • helpful in diagnosing sleep disorders
    • rate probability of falling asleep
    • scale of 0 to 3 for eight different situations that most people engage in during their daily lives,
    • 0-9: normal
    • 11-15: mild/mod sleep apnea;
    • 16-24: severe sleep apnea/narcolepsy
  38. Does daytime sleepiness always accompany Sleep disordered breathing; how many patients mask daytime sleepiness?
    no, we cannot know as it is very variable between individuals.
  39. Apart from daytime sleepiness are many patients aware that they have a sleep disorder?
    no, 67% of adults report >1 sleep disorder, but only 7% have been diagnosed with sleep disorder from MD
  40. What is the difference between a Sleep Disorder and a Sleep Related Breathing Disorder
    • SDB sleep disordered breathing-any type of difficulty breathing; not necessarily pathology
    • SRBD-sleep related breathing disorder = subset; sleep apnea ; pathological
  41. What subdiagnoses of sleep disorders can dentistry legitimately treat?
    snoring, mild and moderate OSA, bruxism
  42. Stop-Bang questionnaire
    • STOP
    • S: Snore
    • T: Tired
    • O: Obstruction. Airway obstruction.
    • P: Pressure problem ?
    • BANG
    • BMI, Age, Neck, Gender
  43. Mallampati score
    • Malampatti (aka modified friedman)
    • -depends on how much of uvula is visible
    • -related to ease of intubation
    • Just have pt open wide-not say 'ah' or stick tongue in/out etc
  44. ● Class I: Soft palate, uvula, fauces, pillars visible.
    • ● Class II: Soft palate, uvula, fauces visible.
    • ● Class III: Soft palate, base of uvula visible.
    • ● Class IV: Only hard palate visible
  45. Mandibular repositioning appliance (MRA)
    • A mandibular splint or mandibular advancement splint (MAS) is a device worn in the mouth that is used to treat obstructive sleep apnea (OSA) and snoring. These devices are also known as mandibular advancement devices
    • The splint treats snoring and sleep apnea by moving the lower jaw forward slightly, which tightens the soft tissue and muscles of the upper airway to prevent obstruction of the airway during sleep. The tightening created by the device also prevents the tissues of the upper airway from vibrating as air passes over them — the most common cause of loud snoring.
    • non-invasive, easily reversible, quiet, and generally well accepted by the patient
    • problems: tooth discomfort; mucosa dryness; tmj discomfort; mild changes in occlusion
  46. NREM and REM sleep
    • NREM takes 75% of TST and coonsists of 3 stages. Stage 1 (2-5% of TST), Stage 2 (45-55% of TST), Stage 3, the deepest, has a delta wave, 25% of TST.
    • REM is the rapid eye movement sleep, dream sleep and it forms 25% of TST. It decreases with age.
  47. Stages of sleep
    The four NREM stages (stages 1, 2, 3, and 4) roughly parallel a depth-of-sleep continuum, with arousal thresholds generally lowest in stage 1 and highest in stage 4 sleep. NREM sleep is usually associated with minimal or fragmentary mental activity. A shorthand definition of NREM sleep is a relatively inactive yet actively regulating brain in a movable body.
  48. Obstructive sleep apnea vs Obstructive sleep apnea syndrome
    • OSA with excessive daytime sleepiness (EDS) is OSAS
    • syndrome = has day time sleepiness
    • Disease doesn’t have EDS.
  49. Sleep disordered breathing (SDB)
    • SDB is the non pathological breathing problems. It is a more global
    • term that includes SRBD, upper airway resistance syndrome (UARS), and snoring,
    • making SDB the most prevalent sleep disorder group.
  50. Periodic limb movements during sleep (PLMS or PLM):
    Periodic limb movements during sleep (PLMS) are typically seen in patients with restless legs syndrome (RLS).
  51. RLS (Restless leg syndrome)
    • a disorder characterized by an unpleasant tickling or twitching sensation in the leg muscles when sitting or lying down, which is relieved only by moving the legs.
    • Occurs in wake and sleep, 10% adults/2% children. leg tingling.
  52. Myoclonus
    spasmodic jerky contraction of groups of muscles. Like PLMS, but movements are more isolated, occurs in transition b/t wakefulness and sleep
  53. PSG (polysomnography) (polysomnogram)-
    also called a sleep study, is a test used to diagnose sleep disorders. It records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study. the diagnosis of sleep disorders by an overnight sleep study called polysomnagram. It is the GOLD STANDARD. It used to be a two night study, now it is a split night study, and more recently OCST.
  54. REM sleep behavior disorder
    Rapid eye movement sleep behavior disorder (RBD) is a sleep disorder (more specifically a parasomnia) that involves abnormal behaviour during the sleep phase with rapid eye movement (REM) sleep. It was first described in 1986.This extends from simple limb twitches to more complex integrated movement, in which sufferers appear to be unconsciously acting out their dreams. These behaviours can be violent in nature and in some cases will result in injury to either the patient or their bed partner.
  55. Cataplexy
    Sudden loss of muscle strength, following an emotional event (eg-laughing)
  56. Sleep paralysis
    Sleep paralysis is a phenomenon in which people, either when falling asleep or wakening, temporarily experience an inability to move. It is a transition state between wakefulness and rest characterized by complete muscle atonia (muscle weakness). It can occur at sleep onset or upon awakening, and it is often associated with terrifying visions, such as an intruder in the room, to which one is unable to react due to paralysis. It is believed to be a result of disrupted REM sleep, which is normally characterized by complete muscle atonia that prevents individuals from acting out their dreams. Sleep paralysis has been linked to disorders such as narcolepsy, migraines, anxiety disorders, and obstructive sleep apnea; however, it can also occur in isolation. When linked to another disorder, sleep paralysis commonly occurs in association with the neurological sleep disorder narcolepsy.
  57. Sleep walking
    also known as somnambulism or noctambulism is a sleep disorder belonging to the parasomnia family. Sleepwalkers arise from the slow wave sleep stage in a state of low consciousness and perform activities that are usually performed during a state of full consciousness. These activities can be as benign as sitting up in bed, walking to the bathroom, and cleaning, or as hazardous as cooking, driving, violent gestures, grabbing at hallucinated objects, or even homicide.
  58. Narcolepsy, and often accompanying additional features
    • Narcolepsy is a neurological sleep disorder. It is not caused by mental illness or psychological problems. It is caused by brain’s inability to control sleep wake cycles. There are two main characteristics of narcolepsy, excessive daytime sleepiness and abnormal REM sleep.Narcoleptics, when falling asleep, generally experience the REM stage of sleep within 5 minutes, while most people do not experience REM sleep until an hour or so later.
    • One of the many problems that some narcoleptics experience is cataplexy, a sudden muscular weakness brought on by strong emotions.
  59. RMMA (Rhythmic masticatory motor activity)
    • complex movements such as infant suckling or tooth grinding
    • Sleep bruxism is primarily associated with RMMA
  60. Tongue retaining device (TRD)
    Oral appliance that is used to treat OSA by retaining the tounge. Tongue-retaining device performance tended to be similar to that of the mandibular advancement device. Thus, it as an alternative to continuous positive airway pressure, taking nasal obstruction into consideration as a contraindication.
  61. UPPP (uvulopalatopharyngoplasty)
    a procedure that removes excess tissue in the throat to make the airway wider. This sometimes can allow air to move through the throat more easily when you breathe, reducing the severity of obstructive sleep apnea (OSA).
  62. What is a sleep histogram- graph indicating sleep stages thoughout the night.
  63. Sleep stages as a proportion of total sleep. How does it change from infant to adult to elderly
    • - Get less and less REM sleep
    • - Overall sleep time decreases as well
    • - Stage III sleep: 25% (young adults ) → <5% (elderly)
    • - REM sleep: 50% (infants) → 25% (young adults)
  64. What part of the period of sleep has the most REM
    REM occurs in the second half of sleep. Time in REM increases as you sleep more, while time spent in Stage III decreases
  65. Developmental effect of sleep disordered breathing or bad sleep in infants
    Cognitive, ADHD, decrease in IQ.
  66. What medical problems are amplified by sleep disordered breathing?
    • CVS: Heart attacks, atherosclerosis, hypertention, coronary artery disease.
    • Brain: Stroke, decrease in cognition, headache, decrease in vigilance
    • Metabolic: diabetes, glucose intolerance, obesity
    • Systemic: depression, psychosocial, cancer pain.
    • Mortality.
  67. Even in the absence of complaint of sleep problems, what medical findings in the patients history should prompt you to take a sleep history because of the high prevalence associations?
    Diabetes, CV disease, GERD, brain damage
  68. Why is it wrong for the dentists to treat snoring without a sleep lab study, or in the absence of a diagnosis of benign snoring from the patient’s MD?
    First there should be a diagnosis to start any treatment and for legal issues, by law, the diagnosis should be done by an MD.
  69. What percentage of problem snorers have sleep apnea
    50%
  70. If a patients stops snoring after they self treat with an OTC or a DDS makes a mandibular advancement appliance, does this mean they no longer have obstructive sleep apnea or central apnea?
    NO. OSA is a structural problem. It is a anatomy and function problem.
  71. Although helpful and necessary, does reduction of morbid obesity definitely treat obstructive sleep apnea, and solve the obstructive sleep apnea problem?
    No
  72. What questions should you include in you patient intake questionnaire or ask the patient and their partner as the first step to screening for sleep apnea?
    • how long does it take for you to sleep → right away, I cannot even remember when I put my head on pillow → sleep is deprived.
    • STOP
    • S: Snore
    • T: Tired
    • O: Obstruction. Airway obstruction.
    • P: Pressure problem ?
  73. What oral and pharyngeal features should you examine for and record, as possible contributing factors in obstructive sleep apnea ?
    • Gag reflex, malmapatti score
    • Skeletal relationship
    • Arch forms
    • Tonsils
    • Uvula
    • Soft/hard palate (hard palate is bad)
    • Nares, turbinates
    • Neck
    • Waist
    • BMI
    • Resting SaO2
  74. What is meant by a titratable mandibular advancement appliance to treat obstructive sleep apnea
    You “titrate” it, as in move the mandibular advancement device bit by bit until right wanted length is reached with the Oral appaliance.
  75. What informed consent should a dentist give before making and delivering a mandibular advancement appliance to treat obstructive sleep apnea, including possible iatrogenic consequences ?
    Risk benefits, OAT may aggravate TMJ disease in certain patients of increase tendency for bruxism, orthodontic effects on the teeth, bite changes, and dentofacial structures. Tenderness of the teeth and jaw, gum irritation, excessive salivation or xerostomia. MIld pain and strain of masticatory muscles and the TMJ. Potential fracturing of teeth or restorations.
  76. Can traditional sleep bruxism appliances worsen obstructive sleep apnea
    yes, because it occupies part of the mouth.
  77. Can/should the DDS treat obstructive sleep apnea without a medical referral and prescription?
    ● No. you need a dx from physician first
  78. What does sleep apnea do to the amount of the stages and pattern of sleep (sleep histogram)?
    Lessen the amount of REM sleep
  79. Is sleep bruxism caused by dental malocclusion and is treatable by occlusal therapy or nightguards.
    No
  80. What questions would you ask your patient and what would you examine/clinical findings to determine if the patient is a current sleep bruxer
    • (dont know if this is right, but googled it and found on NCBI):
    • ● GI symptoms also may provoke or worsen sleep derangements. Reflux of gastric acid is a less frequent event during sleep, however, acid clearance mechanisms (including swallowing, salivation and primary esophageal motility) are impaired during sleep resulting in prolongation of acid contact time. Nighttime reflux can lead to sleep disturbance and sleep disturbance may further aggravate GERD by prolonged acid contact time and heightened sensory perception.
  81. Does wearing a night guard treat daytime jaw clenching?
    NO
  82. Sleep bruxism is best classified as a Sleep Related Movement Disorder (SRMD): what other diagnoses are included in SRMD?
    RLS, PLMS (periodic limb movements of sleep), RMMA, leg cramps, bruxism, snoring
  83. How does GERD worsen a sleep breathing disorder?
    Inflamation caused by the GERD causes the airway to narrow.
  84. Why should the dentist take a sleep history and perform an oropharyngeal examination before performing extraction and retraction orthodontics, and before doing mandibular set back orthognathic surgery ?
    Can’t treat  patient without proper diagnosis
  85. What are the indications, and possible contraindications, for performing mandibular maxillary advancement surgery to treat sleep apnea ?
    • Surgical management of snoring and OSA is indicated when a surgically correctable abnormality is believed to be the source of the problem and the patient has tried continuous positive airway pressure (CPAP) without success. In addition, many patients opt for surgical treatment after noninvasive forms of treatment have proven ineffective or difficult to tolerate.
    • Surgical alteration of the upper airway usually involves 1 or more structures, such as the nasal septum, inferior nasal turbinates, adenoids, tonsils, anterior and posterior tonsillar pillars, uvula, soft palate, and base of the tongue. Craniofacial abnormalities, whether acquired or congenital, may also be amenable to surgical correction. In unusual cases, obstruction may occur at the level of the larynx (eg, tumor, laryngomalacia).
    • Palatal surgery is contraindicated in patients with velopharyngeal insufficiency or a submucous cleft palate. Medical conditions that preclude the use of a general anesthetic are a relative contraindication to surgery.
    • And CSA.
  86. Sleep halves
    • REM sleep increases during the second half of sleep.
    • Most of deep sleep in the first half of the sleep.
  87. med conditions & SDB
    • brain: episodic hypoxia -> impaired cognition/ memory/learning
    • brain: gray matter loss (motor regulation/cognitions), diminished, PS(parasymp) outflow
    • child brain: dec IQ, executive function (hippocampus, frontal cortex)
    • CV: endothelial dysfunction, HTN, oxidative stress (Herbst MAS works)
    • medabolic syndrome
  88. Jaw advancement & brain
    mand adv w/ oral device->reduces respirator stress of brain involved with upper airway
  89. metabolic syndrome
    • HTN
    • glucose intolerance
    • low HDL
    • high triglycerides
  90. morbid obese
    • BMI>=40
    • 2/3 OSAHS, 1/3 of them severe
  91. sleep & eating
    dec sleep, dec Leptin, inc Ghrelin, inc appetites
  92. GERD & SDB
    • ~60%
    • CPAP tx both (not dental)
  93. BAC ~ insomnia
    • 0.05 ~ 17 hrs
    • 0.10 ~ 24 hrs
    • most legal limit 0.08
  94. dental sleep medicine
    • manage SDB (snoring and OSA) w/ OAT and UA surgery
    • OAT: customized select, fabricated, fitted adjested for long term follw up
    • dx of SDP: by PHYSICIANS
  95. AHI
    • mild: 5 and 15,
    • moderate: 15 and 30
    • severe >30
    • 50% reduction in AHI is frequently cited to assess whether this respiratory condition is being successfully managed using a continuous positive airway pressure device or MAD, although a reduction in AHI below 10 or 20 has also been considered a necessity for success
  96. reticular thalamic nucleus
    • blocks sensory input from body from reaching the cerebral cortex during non-REM sleep
    • involves gamma aminobuteric acid (GABA)
    • most robust filtering: N3 -> hormonal changes(GH)
  97. REM neurotransmitters
    • Ach, NE, 5HT
    • dorsal raphe nucleus (5HT)
    • locus coeruleus (NE)
    • which suppress PPT nucleus (Ach to lower brainstem and thalamus)
    • REM is when this supression is stopped
    • PPT1: thalamus (dreams)
    • PPT2: medulla->reticulo-spinal (Gly)(paralysis)
  98. Increased sleepiness throughout the day results from a heightened level of filtering from the _____ as it attempts to put the brain to sleep.
    reticular thalamic nucleus
  99. Bernoulli Effect
    • flow
    • goes through a space, there is a negative
    • pressure or vacuum that develops within
    • that space. If the space becomes narrower
    • and the flow volume is maintained
    • constant then there is an increase in the
    • degree of negative pressure or vacuum.
  100. partial obstructions lasting 10 seconds
    • or longer are known as
    • hypopneas
  101. respiratory effort-related arousals of sleep (RERAS)
    subtle events trigger the muscles of the throat, tongue, and mandible, increasing muscle tone and opening the airway to normalize respirations
  102. upper airway resistance syndrome (UARS)
    • When an individual has fragmented
    • sleep and sleepiness primarily resulting from
    • respiratory effort-related arousals of sleep (RERAS)
  103. split night study problem
    • REM sleep occurs more toward the
    • last portion of the night there would be a
    • minimal amount of REM sleep measured
    • with a split night study
  104. the upper airway is more resistant to collapse
    • during
    • slow wave or N3 sleep
  105. CPAP works by providing positive pressure to nullify the
    Bernoulli Effect
  106. SB and OSA
    • SB or clenching may occur as a mechanism
    • to prevent airway collapse
    • Treatment of obstructive breathing with
    • CPAP alone reduces the bruxism/clenching
    • and improves TMD symptoms in a
    • high percentage of patients.
  107. Nasal Procedures
    • Rhinoplasty & Nasal Valve Surgery
    • Septoplasty
    • Sinus Surgery
    • Turbinate Surger
  108. Palate Procedures
    • Expansion Sphincter Pharyngoplasty
    • Lateral Pharyngoplasty
    • Palate Radiofrequency
    • Palate Surgery
    • Pillar Procedure
    • Uvulopalatoplasty (Laser or Cautery-Assisted)
  109. Tongue Region Procedures
    • Epiglottis Surgery
    • Genioglossus Advancement
    • Hyoid Suspension
    • Lingual Tonsillectomy
    • Midline Glossectomy
    • Tongue Radiofrequency
  110. Important percentages and info:
    • ⅓ of US population suffer from sleep disorders
    • insomnia 25% of population
    • SRBD OSA(S) M 24% (4%) F 9%(2%)
    • Narcolepsy 0.05%
    • snoring M 40% F 24%
    • by age 60 M 60% F 40%
    • (by 30-35 M 20% F 5%)
    • morbidly obese m 90% f 50%
    • 1-3% of MVC reported due to drowsiness in US. Average in developed countries is 20%
  111. Maxillary transverse distraction osteogenesis
    advantage that not only is the maxillary dentoalveolus widened, but also the floor of the nose
  112. Müller's maneuver
    • After a forced expiration, an attempt at inspiration is made with closed mouth and nose, whereby the negative pressure in the chest and lungs is made very subatmospheric; the reverse of Valsalva manoeuvre.
    • Evaluate collapsed sections, identify weakened sections of the airway.
    • positive test result means the site of upper airway obstruction is likely below the level of the soft palate, and the patient will probably not benefit from a uvulopalatopharyngoplasty alone. This maneuver is very helpful in doing MRI for sleep apnoea, when sedation to patient can be avoided.
  113. PM at minimum should record: airflow, respiratory effort, SaO2
  114. Portable Monitors are unlikely to help in evaluation of other sleep disorders
    • – Central sleep apnea
    • – Periodic limb movement disorder (PLMD)
    • – Insomnia
    • – Parasomnias
    • – Circadian rhythm disorders
    • – Narcolepsy
  115. Portable testing may not be appropriate for patients with co-morbid medical conditions
    • – Moderate to severe pulmonary disease
    • – Neuromuscular disease
    • – Congestive heart failure
    • Also Pediatric and Older populations?
  116. Cataplexy
    • sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, terror, etc.[
    • Cardinal symptom of narcolepsy with cataplexy affecting roughly 70% of people who have narcolepsy,[2] and is caused by an autoimmune destruction of the neurotransmitter hypocretin, which regulates arousal and wakefulness.
  117. Sleep paralysis
    • when falling asleep or wakening, temporarily experience an inability to move. It is a transition state between wakefulness and rest characterized by complete muscle atonia (muscle weakness).
    • It can occur at sleep onset or upon awakening, and it is often associated with terrifying visions, such as an intruder in the room, to which one is unable to react due to paralysis. It is believed to be a result of disrupted REM sleep, which is normally characterized by complete muscle atonia that prevents individuals from acting out their dreams. Sleep paralysis has been linked to disorders such as narcolepsy, migraines, anxiety disorders, and obstructive sleep apnea; however, it can also occur in isolation.[1][2] When linked to another disorder, sleep paralysis commonly occurs in association with the neurological sleep disorder narcolepsy
  118. ulopalatopharyngoplasty
    • (also known by the abbreviations UPPP and UP3) is a surgical procedure or sleep surgery used to remove tissue in the throat. It involves the removal of tissues which may or may not include:
    • The uvula (see uvulotomy)
    • The soft palate.
    • The tonsils
    • The adenoids, and
    • The pharynx.
  119. cephalometric factors
    • mand hypoplasia
    • inferior hyoid
    • elongated soft palate
    • narrow airway
  120. mand advancement appliances place mandible at:
    75% of max physologic protrusion

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