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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 1  |  Page : 3-5

Imaging obstructive sleep apnea: Role of oral medicine and maxillofacial radiologists

Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Date of Submission06-Mar-2021
Date of Acceptance07-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Ashok Lingappa
Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere-4, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_64_21

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How to cite this article:
Lingappa A. Imaging obstructive sleep apnea: Role of oral medicine and maxillofacial radiologists. J Indian Acad Oral Med Radiol 2021;33:3-5

How to cite this URL:
Lingappa A. Imaging obstructive sleep apnea: Role of oral medicine and maxillofacial radiologists. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 Oct 3];33:3-5. Available from: https://www.jiaomr.in/text.asp?2021/33/1/3/312211

“Sleep is that Golden chain that ties the Health and our body together”

“A good laugh and good sleep are the two best cures for anything”

It is the most under-rated functions of the body and also, the one to be most often sacrificed when deadline looms or in stressful situation. These are those peaceful 6 to 8 hr of the day, when our brain tries to get rid of all the toxins it has accumulated, leading to a peaceful day and a successful life ahead.

Sleep-related disorders are becoming very common in the recent days affecting the quality of life of an individual. One of such is obstructive sleep apnea (OSA), a common chronic disorder affecting about 2–4% of the adult population, with the highest prevalence reported among middle-aged men. The prevalence rate is 19.5% among men and 7.5% among women in India.[1]

This condition is characterized by repetitive episodes of complete or partial collapse of the upper airway (mainly the oropharyngeal tract) during sleep, with a consequent cessation/reduction of the airflow. OSA causes severe symptoms, such as excessive daytime somnolence, and is associated with a significant cardiovascular morbidity and mortality.[2]

The obstructive events (apneas or hypopneas) can cause a progressive asphyxia that increasingly stimulates breathing efforts against the collapsed airway, typically until the person is awakened. The etiology of this condition is multifactorial and consists of the interplay between anatomical structures and neuromuscular factors. Risk factors like obesity, age, and comorbidities like hypertension and endocrinal disorders also play a significant role. Many patients can develop cognitive and neurobehavioral dysfunction, inability to concentrate, memory impairment, and mood changes, such as irritability and depression. This further impairs performance at work with a remarkable effect on the quality of life.[3]

Sleep disorders in children are often a commonly diagnosed diagnosed problem. They occur most often in a form of OSA syndrome, described in the literature for the first time in 1976. Recently, in 2002, the American Academy of Pediatrics recognized snoring in children as a major medical problem in this age group and published the first report concerning sleep apnea diagnostics and treatment in children. Ten years later, in 2012, the Academy amended these guidelines. European Respiratory Society Task Force published a document in a form of seven steps referring to the obstructive sleep disordered breathing and detailed therapeutic approach.[4]

OSA seems to be a hot topic in the world of dentistry. The level of awareness of sleep apnea and related health issues is growing rapidly among the various dental specialists including the oral medicine and maxillofacial radiologist, which is brought about by new diagnostic measures and treatment options. What was once the purview of the physician, OSA diagnosis and treatment is now intersecting with dentistry.[5]

Today, the diagnosis and treatment of OSA depends on a multidisciplinary team of health professionals including the dentist. The emergence of dental sleep medicine is an area of practice that focuses on the management of sleep-related breathing disorders in conjunction with the pulmonologists and otolaryngologists highlighted the role of dentist in the sleep medicine team.[3],[5]

The oral medicine specialist has a fundamental role in OSA recognition and screening through history, clinical examination, and radiographs that are part of their work.

Medical history (e.g., snoring) and clinical examination allow the oral physician to identify the risk factors of OSA or signs related to OSA (obesity, allergy, nasal dysfunction, maxillary constriction, retrognathia, long uvula, and mouth breathing) and validated questionnaires (Epworth; STOP-BANG; Berlin questionnaire) to screen for sleep-related breathing disorders.[3]

Certain characteristics of the craniofacial structures were found to be common in patients with OSA. Brachyfacial type was found to be more associated with severe apnea than the dolichofacial type. A meta-analysis considered the mandibular body length as the most potentially significant factor associated. There has been growing interest in narrow maxillary arch as a predisposing factor for OSA, because a narrow upper dental arch is also thought to diminish the oropharyngeal volume available for the tongue.[6]

The typical facial features of OSA include mandibular deficiency, bimaxillary retrusion, short cranial base, reduced cranial base angle and mandibular length, increased lower anterior facial height, craniocervical angulations, inferiorly positioned hyoid, and enlarged soft palate.[7]

Soft tissue features associated with OSA patients are narrower retropalatal and retroglossal airway space, thicker and longer soft palate, reduced angle between the uvula tip and anterior nasal spine and greater tongue mass. In imaging of head and neck region for the assessment of OSA, the key areas of evaluation includes the soft palate length, the total oropharyngeal airway length, the position of the hyoid, and any craniofacial or cervical abnormalities.[6],[8]

Several imaging modalities like lateral and frontal cephalogram, cone beam computed tomography, magnetic resonance imaging in addition to polysomnography as the goldstandard investigative procedure in assessment of this condition. Polysomnography also called sleep study records the brain waves, the oxygen saturation levels in the blood, heart, and breathing as well as eye and leg movements.[9]

In maxillofacial radiology, lateral cephalometry is a readily available, standardized, inexpensive, and reliable technique for assessing the pharyngeal airways, whereby details of skeletal and soft tissue structures can be accurately measured and compared with extensive normative data. For example, anteroposteriorly, both the face and anterior cranial base tend to be retruded and the cranial base angle is reduced in OSA patients, which leads to a reduction in the space available for the airway.[10]

For many years two-dimensional (2D) cephalometric images have been used to look for anatomic differences between OSA patients and normal subjects, however the complex shape of the airway is not fully appreciated except with three-dimensional (3D) images. For instance, soft-tissue collapse under conditions of negative airway pressure has been described[5] but the exact location and anatomic risk factors that determine the site of collapse are still debated. Answering this question will require 3D imaging techniques including static imaging [magnetic resonance imaging (MRI), computed tomography (CT), cone-beam CT and dynamic imaging (cine-CT, electron beam computed tomography), cine MRI.[9]

There is a major benefit of cone-beam CT imaging. It provides an anatomical evaluation of the airway at a lower radiation dose and cost than traditional multidetector CT to detect possible obstructions. It allows the dentist to evaluate the airway and correlate those findings with clinical examination and history; it puts them in the driver's seat in identifying potential OSA sufferers and improving quality of life. With estimates that OSA is undiagnosed in 82% –93% of adults, dentists can be at the forefront in screening for the disease.[11],[12]

Cone beam computed tomography (CBCT) provides a detailed depiction of the airway and craniofacial anatomy that allows the clinician or radiologist to identify normal anatomy, variant anatomy, or pathological conditions that may cause obstruction of the airway. This invaluable information, combined with clinical screening, can help identify individuals that may suffer from sleep apnea. Indeed, with OSA afflicting a broad spectrum of people and dangerously underdiagnosed, dentists can serve on the front line of screening. Further supporting the dentists role in screening, CBCT made for dental treatment routinely includes portions or all of the upper airway and is made at a lower radiation dose and cost than traditional multidetector CT used in medicine. Dentists and cone-beam CT are ideally situated for this task.

As an emerging 3D imaging modality, Si CAT software has been shown to be promising in both assessment of the craniofacial features and comparison of measurement of the airway before and after the treatment.[13]

In the last 2 decades, advances in sleep medicine and the availability of improved diagnostic tools have led to a better recognition and treatment of this disease. The management of patients with OSA requires a multidisciplinary approach and many treatment options are currently available. Positive airway pressure, available since the beginning of the 1980s, provides the most effective and commonly used treatment. Alternative options include weight control, mandibular advancement devices, soft plate lifters, tongue repositioning devices, and a number of upper airway surgical approaches.[5]

Mandibular advancement devices, particularly if custom made, are effective in mild to moderate OSA and provide a viable alternative for patients intolerant to continuous positive air pressure therapy (CPAP).[14]

The role of surgery remains controversial. The most appropriate indication is clearly reversible causes of upper-airway obstruction, such as adenotonsillar hypertrophy or mass lesions. Uvulopalatopharyngoplasty is a well-established procedure and can be considered when treatment with CPAP has failed, whereas maxillary–mandibular surgery can be suggested to patients with a craniofacial malformation.[12]

A recent joint statement by the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) states “patients presenting with symptoms of OSA require a face-to-face evaluation conducted by a qualified physician trained in sleep medicine.” The diagnosis of OSA therefore requires consultation with a physician to include clinical examination and diagnostic testing. The clinical evaluation for OSA should incorporate a thorough sleep history and a physical examination that includes the respiratory, cardiovascular, and neurologic systems. Furthermore, polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.[15]

   Conclusion and Future Scope Top

Because the OSA disorders have become the interest of public and increased awareness prompt the dentist to play an important role in early diagnosis, proper treatment plan, and preventing them from potentially fatal diseases. This can provide major improvements in many aspects of patient's quality of life and improve survival, thus decreasing the morbidity and mortality of associated diseases.

   References Top

Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis 2015;7:1311-22.  Back to cited text no. 1
Dempsey JA, Veasey SC, Morgan BJ, O'Donnell CP. Physiology of sleep apnea. Physiol Rev 2010;90:47-112.  Back to cited text no. 2
Tan HL, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: A critical update. Nat Sci Sleep 2013;5:109-23.  Back to cited text no. 3
Medyczne KR. Obstructive sleep disordered breathing in children – an important problem in the light of current European guidelines. Otolaryngol Pol 2018;72:9-16.  Back to cited text no. 4
Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: An American academy of sleep medicine systematic review, meta-analysis, and grade assessment. J Clin Sleep Med 2019;15:301-34.  Back to cited text no. 5
Battagel JM, Johal A, Kotecha B. A cephalometric comparison of subjects with snoring and obstructive sleep apnoea. Eur J Orthod 2000;22:353-65.  Back to cited text no. 6
Banabilh SM. Orthodontic view in the diagnoses of obstructive sleep apnea. J Orthod Sci 2017;6:81-5.  Back to cited text no. 7
Capistrano A, Cordeiro A, Capelozza Filho L, Almeida VC, Silva PI, Martinez S, et al. Facial morphology and obstructive sleep apnea. Dental Press J Orthod 2015;20:60-7.  Back to cited text no. 8
Ara SA, Mujahid F, Patil BM. Role of dental radiologists in diagnosis of patients with high risk of obstructive sleep apnea using lateral cephalogram: A case–control study. Indian J Dent Sci 2019;11:36-41.  Back to cited text no. 9
  [Full text]  
Bhardwaj N, Daniel JM, Srinivasan SV, Jimsha VK. Digital lateral cephalogram as screening tool for obstructive sleep apnea: A preliminary study: J Dent Res Sci Dev 2016;3:2730.  Back to cited text no. 10
Chen NH, Li KK, Li SY, Wong CR, Chuang ML, Hwang CC, et al. Airway assessment by volumetric computed tomography in snorers and subjects with obstructive sleep apnea in a Far-East Asian population (Chinese). Laryngoscope 2002;112:721-6.  Back to cited text no. 11
Ogawa T, Enciso R, Shintaku WH, Clark GT. Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:102-8.  Back to cited text no. 12
Stratemann S, Huang JC, Maki K, Hatcher D, Miller AJ. Three-dimensional analysis of the airway with cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2011;140:607-15.  Back to cited text no. 13
Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015. J Clin Sleep Med 2015;11:773-827.  Back to cited text no. 14
Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J. Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 2004;169:668-72.  Back to cited text no. 15


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