Aim and objective: To evaluate patients presenting to a Dental Hospital's healthcare facility for the factors linked with the development of high-risk obstructive sleep apnea (OSA) through oral and radiographic examination.
Materials and methods: A cross-sectional study was performed to identify the patients at high risk of OSA. The patients were screened with the Snoring, Tired, Observed, and Blood Pressure (STOP)—BANG questionnaire, followed by oropharyngeal examination and lateral cephalography.
Results: Three hundred patients were screened for the risk of OSA out of which 194 (64.6%) were men and 106 (35.3%) were women. One hundred twenty-four (41.3%) belonged to the high-risk group and 176 (58.6%) to the low-risk (control) group. Logistic regression analysis confirmed that in the high-risk OSA group, neck circumference, class 3 or 4 Mallampati scores, temporomandibular disorder (TMD), bruxism, wide tongue, and deep palatal vault were all often seen parameters and were independent indications of developing high risk of OSA. The cephalometric analysis revealed decreased airway spaces in the high-risk group with downward displacement of the hyoid bone.
In the high-risk OSA group, neck circumference, class 3 or 4 Mallampati scores, TMD, bruxism, wide tongue, and deep palatal vault were all often seen parameters and were independent indications of developing high risk of OSA.
Conclusion: This study throws light on the imperative role of orofacial features in screening high-risk OSA patients. Dental sleep medicine is an upcoming branch with diversified treatment modalities. Because OSA has been related to the development of fatal medical disorders, it is critical to educate patients about sleep problems and their consequences.
Clinical significance: Oral and radiographic findings can play a pivotal role in identifying patients at risk for OSA. As the general population is unaware about the systemic implications of OSA, the screening for OSA should be conducted as a routine procedure by oral physicians. Oral examination can be a cost-effective tool in screening OSA.
Huynh NT, Emami E, Helman JI, et al. Interactions between sleep disorders and oral diseases. Oral Dis 2014;20(3):236–245. DOI: 10.1111/odi.12152. Epub 2013 Jul 2.
Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature based analysis. Lancet Respir Med 2019;7(8):687–698. DOI: 10.1016/S2213-2600(19)30198-5
Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: the Hypno Laus study. Lancet Respir Med 2015; 3:310–318. DOI: 10.1016/S2213-2600(15)00043-0
Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177:1006–1014. DOI: 10.1093/aje/kws342
Hasan A, Uzma N, Swamy TL, et al. Correlation of clinical profiles with obstructive sleep apnea and metabolic syndrome. Sleep Breath 2012; 16:111–116. DOI: 10.1007/s11325-010-0463-z
Gianoni-Capenakas S, Gomes AC, Mayoral P, et al. Sleep-disordered breathing: the dentists’ role – a systematic review. J Dent Sleep Med 2020;7(1):1–15. DOI: 10.15331/jdsm
Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2017;13(3):479–504. DOI: 10.5664/jcsm.6506
Flemons WW, Douglas NJ, Kuna ST, et al. Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 2004;169(6):668–672. DOI: 10.1164/rccm.200308-1124PP
Luo J, Huang R, Zhong X, et al. STOP-Bang questionnaire is superior to Epworth sleepiness scales, Berlin questionnaire, and STOP questionnaire in screening obstructive sleep apnea hypopnea syndrome patients. Chin Med J 2014;127(17):3065–3070.
Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108(5):812–821. DOI: 10.1097/ALN.0b013e31816d83e4
Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep Med Rev 2017; 34:70–81. DOI: 10.1016/j.smrv.2016.07.002
Schellenberg JB, Maislin G, Schwab RJ. Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures. Am J Respir Crit Care Med 2000;162:740–748. DOI: 10.1164/ajrccm.162.2.9908123
Sharma SK, Ahluwalia G. Epidemiology of adult obstructive sleep apnea syndrome in India. Indian J Med Res 2010;131:171–175.
Kale SS, Kakodkar P, Shetiya SH. Assessment of oral findings of dental patients who screen high and no risk for obstructive sleep apnea (OSA) reporting to a dental college – a cross sectional study. Sleep Sci 2018;11(2):112–117. DOI: 10.5935/1984-0063.20180021
Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 2016;149(3):631–638.
WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Consultation. WHO Technical Report Series Number 854. Geneva: World Health Organization; 1995.
Oh J, Han JJ, Ryu SY, et al. Clinical and cephalometric analysis of facial soft tissue. J Craniofac Surg 2017;28(5):e431–e438. DOI: 10.1097/SCS.0000000000003614
Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Orofacial Pain Headache 2014;28(1):6–27. DOI: 10.11607/jop.1151
American Academy of Sleep Medicine (AASM). The International Classification of Sleep Disorders Revised: Diagnostic and Coding Manual (ICSD), 2nd edn. Westchester, IL: American Academy of Sleep Medicine; 2005.
Huynh NT, Morton PD, Rompré PH, et al. Associations between sleep-disordered breathing symptoms and facial and dental morphometry, assessed with screening examinations. Am J Orthod Dentofacial Orthop 2011;140(6);762–770. DOI: 10.1016/j.ajodo.2011.03.023
Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42:487. DOI: 10.1111/j.1365-2044.1987.tb04039.x
International Workshop for a Classification of Periodontal Diseases and Conditions. Papers. Oak Brook, Illinois, October 30–November 2, 1999. Ann Periodontol 4:1–112.
Block AJ, Boysen PG, Wynne JW, et al. Sleep apnea, hypopnea and oxygen desaturation in normal subjects. A strong male predominance. N Engl J Med 1979;300(10):513–517. DOI: 10.1056/NEJM197903083001001
Whyte A, Gibson D. Adult obstructive sleep apnea: pathogenesis, importance, diagnosis and imaging. J Med Imaging Radiat Oncol 2020; 64(1):52–66. DOI: 10.1111/1754-9485.12978
Rodrigues MM, Dibbern RS, Goulart CW. Nasal obstruction and high Mallampati score as risk factors for obstructive sleep apnea. Braz J Otorhinolaryngol 2010;76(5):596–599.
Iida-Kondo C, Yoshino N, Kurabayashi T, et al. Comparison of tongue volume/oral cavity volume ratio between obstructive sleep apnea syndrome patients and normal adults using magnetic resonance imaging J MedDent Sci 2006;53(2):119–126.
Ruangsri S, Jorns TP, Puasiri S, et al. Which oropharyngeal factors are significant risk factors for obstructive sleep apnea? An age matched study and dentist perspectives. Nat Sci Sleep 2016;8:215–219. DOI: 10.2147/NSS.S96450
Weiss TM, Atanasov S, Calhoun KH. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Otolaryngol Head Neck Surg 2005;133(6):966–971. DOI: 10.1016/j.otohns.2005.07.018
Gunaratnam K, Taylor B, Curtis B, et al. Obstructive sleep apnea and periodontitis: a novel association? Sleep Breath 2009; 13:233–239. DOI: 10.1007/s11325-008-0244-0
Keller JJ, Wu CS, Chen YH, et al. Association between obstructive sleep apnea and chronic periodontitis: a population-based study. J Clin Periodontol 2013; 40:111–117. DOI: 10.1111/jcpe.12036
Seo WH, Cho ER, Thomas RJ, et al. The association between periodontitis and obstructive sleep apnea: a preliminary study. J Periodontal Res 2013; 48:500–506. DOI: 10.1111/jre.12032
Ahmad NE, Sanders AE, Sheats R, et al. Obstructive sleep apnea in association with periodontitis: a case-control study. J Dent Hyg 2013;87: 188–199.
Blum A, Front E, Peleg A. Periodontal care may improve systemic inflammation. Clin Invest Med 2007;30:E114–E117. DOI: 10.25011/cim.v30i3.1079
Vidal F, Figueredo CM, Cordovil I, et al. Periodontal therapy reduces plasma levels of interleukin- 6, C-reactive protein, and fibrinogen in patients with severe periodontitis and refractory arterial hypertension. J Periodontol 2009; 80:786–791. DOI: 10.1902/jop.2009.080471
Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep 2009; 32:779–790. DOI: 10.1093/sleep/32.6.779
Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet 2005; 14:135–143. DOI: 10.1093/hmg/ddi013
Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res 2013;92(7):70S–77S. DOI: 10.1177/0022034513488140
Cunali PA, Almeida FR, Santos CD, et al. Prevalenceof temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy J Orofac Pain 2009; 23(4):339–344.
Balasubramaniam R, Klasser GD, Cistulli PA, et al. The link between sleep bruxism, sleep disordered breathing and temporomandibular disorders: an evidence-based review. J Dent Sleep Med 2014;1(1):27–37.
Durán-Cantolla J, Alkhraisat MH, Martínez-Null C, et al. Frequency of obstructive sleep apnea syndrome in dental patients with tooth wear. J Clin Sleep Med 2015;11(4):445–450. DOI: 10.5664/jcsm.4602
Al-Madani GH, Banabilh SM, El-Sakhawy MM. Prevalence of snoring and facial profile type, malocclusion class and dental arch morphology among snorer and nonsnorer university population. J Orthod Sci 2014;4(4):108–112. DOI: 10.4103/2278-0203.173424
Triplett WW, Lund BA, Westbrook PR, et al. Obstructive sleep apnea syndrome in patients with class II malocclusion. Mayo Clin Proc 1989;64(6):644–652. DOI: 10.1016/s0025-6196(12)65342-7
Banabilh SM, Samsudin AR, Suzina AH, et al. Facial profile shape, malocclusion and palatal morphology in Malay obstructive sleep apnea patients. Angle Orthod 2010;80(1):37–42. DOI: 10.2319/011509-26.1
Palm E, Franklin KA, Marklund M. Mandibular tori size is related to Obstructive sleep apnea and treatment success with an oral appliance. Sleep Breath 2014; 18:431–438. DOI: 10.1007/s11325-013-0905-5
Singh GD, Cress SE, McGuire MK et al. Case report: effect of mandibular tori removal on obstructive sleep apnea parameters. Dialogue 2012;1:22–24.
Phillips BA, Okeson J, Paesani D, et al. Effect of sleep position on sleep apnea and parafunctional activity. Chest 1986; 90:424–429. DOI: 10.1378/chest.90.3.424
Lavigne GJ, Khoury S, Abe S, et al. Bruxism physiology and pathology: an overview for clinicians. J Oral Rehabil 2008; 35:476–494. DOI: 10.1111/j.1365-2842.2008.01881.x
Winck M, Drummond M, Vianac P, et al. Sleep bruxism associated with obstructive sleep apnea syndrome–a pilot study using a new portable device. Rev Port Pneumol 2017;23(1):22–26. DOI: 10.1016/j.rppnen.2016.07.001
Gungor AY, Turkkahraman H, Yilmaz HH, et al. Cephalometric comparison of obstructive sleep apnea patients and healthy controls. Eur J Dent 2013;7(1):48-54.
Szymanska J, Dobrowolska-Zarzycka M. The influence of upper airways diameter on the intensity of obstructive sleep apnea. Ann Agric Environ Med 2014;21: 217–220. DOI: 10.5604/12321966.1095371
Martin SE, Mathur R, Marshall I, et al. The effect of age, sex, obesity and posture on upper airway size. Eur Respir J 1997;10:2087–2090. DOI: 10.1183/09031936.97.10092087
Arya D, Tripathi A, Singh SV, et al. A pilot study to evaluate posttreatment cephalometric changes in subjects with OSA. J Prosthet Dent 2010;103:170–177. DOI: 10.1016/S0022-3913(10)60024-8
Mayer G, Meier-Ewert K. Cephalometric predictors for orthopaedic mandibular advancement in obstructive sleep apnea. Eur J Orthod 1995;17:35–43. DOI: 10.1093/ejo/17.1.35
Armalaite J, Lopatiene K. Lateral teleradiography of the head as a diagnostic tool used to predict obstructive sleep apnea. Dentomaxillofac Radiol 2016; 45:20150085. DOI: 10.1259/dmfr.20150085
Lavanya R, Gandhi Babu DB, Chavva S, et al. The role of oral physicians in predicting the risk of obstructive sleep apnea: a case-control study. Imaging Sci Dent 2016;46(3)167–171. DOI: 10.5624/isd.2016.46.3.167
Julià-Serdà G, Pérez-Peñate G, Saavedra-Santana P, et al. Usefulness of cephalometry in sparing polysomnography of patients with suspected obstructive sleep apnea. Sleep Breath 2006; 10:181–187. DOI: 10.1007/s11325-006-0073-y