4. What is Sleep Apnea? Steadman’s Medical Dictionary defines “apnea” as the absence of breathing or the want of breath. When there is a cessation of airflow at the mouth and nose for more than 10 seconds

5. Hypopnea – Medicare: An abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in airflow, 4% oxygen desaturation and an arousal. Non-medicare: >50% drop in the nasal pressure signal compared to baseline associated with either a 3% desaturation or an arousal.

6. AHI – Apnea-Hypopnea Index is the number of apneas plus hypopneas per hour of sleep.

7. OSA – Obstructive Sleep Apnea Syndrome Apneas and/or hypopnea events occurring at least 5 times per hour. Events accompanied by oxygen desaturations of 4% or more. Events accompanied by arousals. Arousals lead to chronic daytime sleepiness.

8. Physiologic Effects of OSA: Asphyxia—lack of breathing Hypoxemia—reduced blood oxygen desaturation Hypercapnia—increased carbon dioxide in blood Acidosis—as a result of accumulation of CO Cardiovascular consequences—to be discussed Sleep fragmentation—leading to daytime sleepiness

9. Predisposing Factors Age: Prevalence progressively increases with advancing age. Obesity: Prevalence progressively increases with increasing weight. Gender: 4 times more common in men; but post- menopausal women have snoring/OSA at same prevalence as men of same age. Disproportionate upper airway anatomy Alcohol or sedative-hypnotics in evening Hypothyroidism

10. Snoring can be categorized by its severity. On one side of the spectrum, you have the benign snorer, who snores but experiences no physical problems. On the other side of the spectrum, you have the snorer who suffers from apnea, and in the middle you have the snorer who suffers from what we call UPPER AIRWAY RESISTANCE SYNDROME

12. Apnea severity is usually categorized by the frequency of apnea episodes. 5-15 episodes per hour is Mild, 15-25 episodes per hour is Moderate, and more than 30 episodes per hour is considered Severe.

13. Medical Exam If you have symptoms for OSA, most likely will include a polysomnogram.

14. Patient History Daytime Drowsiness (ESS) - Effect on daily activities – Cognitive Impairment – Refreshed/Un-refreshed on awakening – Motor vehicle accidents or near misses while driving – Sleep apnea is not the only reason for daytime www.somnomed.com

15. Patient History Snoring Frequency Loudness Effect on Sleep of others www.somnomed.com

16. Heavy snoring Gasping or choking during the night Excessive daytime sleepiness Frequent arousals during sleep (fragmented sleep) Non-refreshed sleep Restless sleep Morning headaches Nausea Personality changes such as becoming irritable or temperamenta l ADULTS

17. Severe anxiety or depression Poor job performance Clouded memory Intellectual deterioration Occupational accidents Impotence Decreased sex drive Bruxing Dry mouth when you awaken Scratchy throat

18. TREATMENT OPTIONS

19. CPAP

20. SURGERY

21. ORAL APPLIANCE

22. Adjustable PM Positioner A lot of tongue space; limited movement

23. Thornton Adjustable Positioner (TAP®) Limited movement because of anterior hook Biggest disadvantage is that it takes up tongue space Advantage is that it can be adjusted easily during a sleep study

24. Herbst Appliance (Traditional hardware) Ball attachments Difficult to see arrows and each turn is.2mm Approved for sleep apnea for Medicare and Medicaid

25. SomnoMed MAS TM (Dorsal Appliance) Work well; side screws for titration Fit well Okay for clencher, not bruxer; wings limit lateral movement Have lab place ball hooks for vertical elastics so they are in place if needed

26. SUAD I wear Cast metal framework as part of appliance Great for bruxers Washers for titration—easy to see

27. NARVA L Hard to adjust material They do not design full occlusal coverage Titration arms only in 1mm increments I don’t care for horizontal arm Durability?

28. OASIS Bulky No measurement for titration Screws $25 each and strip easily

29. SILENT NIGHT Not approved for sleep apnea Works well for snoring Lasts approximately three years – acrylic will stain

30. Custom made; cover all teeth and wrap distal of the molars—DURABLE Titratable within > 0.5mm Tongue space What I Look for in an Appliance…

31. 1.Understand what sleep apnea is and the health ramifications. 2.Be certain to obtain a copy of the patient’s polysomnogram or home sleep study. Remember we need the physician to diagnose sleep apnea. Understand the severity of sleep apnea that you are dealing with. Also, is it obstructive or central apnea? 3.Work with the patient’s general physician or sleep physician. This is critical correspondence. a. Write a letter to the physician or sleep physician informing them that you are seeing their patient. b. Let them know what type of treatment you are providing; i.e., what appliance. c. General length of time for treatment. d. Send progress letter.

32. 4.Documentation of treatment. I do like to ask set questions each visit to see how treatment is progressing. 5.When you have achieved your desired results, have the patient do a polysomnogram or home sleep study. **Key point – With this information you have accurate data on how you have been able to treat and help the patient. 6.Send a letter to general physician and sleep physician informing them of treatment results. 7.Have six-month follow up visits to track the effectiveness of the appliance.