Faculty of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Benvinda de Carvalho, 105/101, Santo Antônio, Belo Horizonte, Minas Gerais, BrazilBrazil
Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Universidade Federal de Minas Gerais – Av. Antônio Carlos 6627, Belo Horizonte, MG 31270-901, Brazil Central sleep apnea is a sleep-related breathing disorder characterized by repetitive cessation or decrease of both airflow and respiratory effort during sleep.
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Central sleep apnea is a sleep-related breathing disorder characterized by repetitive cessation or decrease of both airflow and respiratory effort during sleep. Conversely, in obstructive sleep apnea (OSA) there is a respiratory effort against a closed upper airway evidencing that patients who suffer from OSA have anatomic/functional deficits in the upper airways.
Open Journal Short Obstructive Sleep Apnea and Oral Communication Appliances * *Corresponding author Ana Paula Hermont, PhD, MSc, BDS 1 2* Department of Pediatric Dentistry and Maria de Lourdes Rabelo Guimarães, BDS, DMD1; Ana Paula Hermont, PhD, MSc, BDS2* Orthodontics Faculty of Dentistry 1 Faculty of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Universidade Federal de Minas Gerais – Av. Antônio Carlos 6627 Benvinda de Carvalho, 105/101, Santo Antônio, Belo Horizonte, Minas Gerais, Brazil Belo Horizonte 2 Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Universidade MG 31270-901, Brazil Federal de Minas Gerais – Av. Antônio Carlos 6627, Belo Horizonte, MG 31270-901, Brazil Tel. +5531997618587 E-mail: anapaulahermont@gmail.com Volume 2 : Issue 1 Central sleep apnea is a sleep-related breathing disorder characterized by repetitive Article Ref. #: 1000EPOJ2109 cessation or decrease of both airflow and respiratory effort during sleep.1 Conversely, in obstructive sleep apnea (OSA) there is a respiratory effort against a closed upper airway evidencing that patients who suffer from OSA have anatomic/functional deficits in the upper Article History airways.2 When associated with clinical signs and symptoms such as excessive daytime th Received: December 12th, 2016 sleepiness, cognitive deficit, decreased quality of life (QoL) and increased cardiovascular th 3-5 Accepted: January 4 , 2017 morbidity it is called obstructive sleep apnea syndrome (OSAS). th Published: January 6th, 2017 In clinical practice it is noticeable that rarely do patients suffer from pure OSAS, the majority of them exhibits some proportion of central and/or mixed events. The coexistence of Citation two types of apnea indicates more complex underlying disorders than just increased resistance Guimarães MLR, Hermont AP. Ob- in the upper airway. In fact, unstable respiratory control has been implicated in the pathogenesis structive sleep apnea and oral appli- ances. Epidemiol Open J. 2017; 2(1): of both central and obstructive sleep apnea. 16-18. doi: 10.17140/EPOJ-2-109 Oral appliances (OA) are recommended exclusively as a treatment option for OSAS. In the literature, 3 large groups of OA are found: tongue retaining devices, anterior mandibular repositioning devices and lifting devices of the soft palate and uvula. Combined therapy using intraoral positive-pressure devices can also be used.6 Nowadays, the category of anterior mandibular repositioning devices is by far the most common type of OA in use.7 Many different device designs have contributed towards the misunderstanding related to the success of the treatment. In order to correct these deficiencies, a consensus conference was held to develop an evidence-based definition of an effective OA for the treatment of sleep-related breathing disorders and to establish a standard reference for research and clinical practice. Thus, the American Academy of Dental Sleep Medicine (AADSM) has determined that the OA terminology refers to mandibular advancement devices because they are the most effective and widely used in clinical practice. However, this definition will be re-evaluated and revised as new methods and evidences become available. Innovations have been released in 8-11 OSA treatments, including advances in relation to OA treatment.8-11 Although OA are indicated exclusively for the treatment of OSA, a study published in 1991 showed two cases of patients with central apnea treated with this device.12 The pathophysiology of central sleep apnea syndrome has not yet been fully clarified, but obstruction of the upper airway may be one of the causes.13 This relationship between central sleep apnea Copyright and partial obstruction of the upper airway was suggested in a study in which a continuous ©2017 Hermont AP. This is an positive airway pressure device (CPAP), administered to improve respiratory load during sleep, open access article distributed un- eliminated central sleep apnea in patients who had narrow upper airways, but it had no positive der the Creative Commons Attribu- effect on central apnea in patients with brainstem lesions.
tion 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction Central sleep apnea emergent to the treatment of OSA has been described, especially in any medium, provided the origi- after therapy with positive airway pressure (PAP) device. However, it is important to be nal work is properly cited.
15 16 aware that central apneas can also arise by treatment with OA. Thomas et al has used OA in patients with complex apnea and who are intolerant to PAP Automobile accidents in patients with sleep apnea syndrome. An with reasonable success. According to these authors, residual epidemiological and mechanistic study. Am J Respir Crit Care sleep apnea may occur when using OA and it requires adjuvant Med. 1998; 158(1): 18-22. doi: 10.1164/ajrccm.158.1.9709135 therapy. Once OA are less likely to induce hypocapnia and are also less effective in treating obstructions, the researcher has 4. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, used “cocktails” in the treatments including OA. He has used Mohsenin V. Obstructive sleep apnea as a risk factor for stroke a combination with acetazolamide, or a benzodiazepine, or and death. N Engl J Med. 2005; 353: 2034-2041. doi: 10.1056/ supplemental oxygen.
NEJMoa043104 In our clinical routine we have observed that the 5. Sleep-related breathing disorders in adults: recommendations polysomnography of patients with OSA often does not for syndrome definition and measurement techniques in clinical exhibit central and mixed events in the reports. We believe research. The Report of an American Academy of Sleep it happens due to the fact that scores of respiratory events in Medicine Task Force. Sleep. 1999; 22: 667-689.
patients with sleep apnea have traditionally been inclined to an obstructive phenotype, although the recent 2007 update of the 6. SD Smith. Oral appliances in the treatment of obstructive AASM guidelines established some criteria to quantify central sleep apnea-hypopnea syndrome. RCOE. 2002; 7(4): 391-402.
hypopneas and short sequences of periodic breathing/cheyne- stokes respiration.17 7. Hoffstein V. Review of oral appliances for treatment of sleep- disordered breathing. Sleep Breath. 2007; 11(1): 1-22. doi: Scoring guidelines for respiratory events predict that 10.1007/s11325-006-0084-8 central hypopneas should not be marked in the presence of flow limitation, but obstruction isa common feature of central events.16 8. Scherr SC, Dort LC, Almeida FR. Definition of an effective Direct visualization of the upper airway commonly shows oral appliance for the treatment of obstructive sleep apnea and collapse in the nadir of the cycle, even in polysomnography of snoring: A report of the American Academy of Dental Sleep the “central” disease. Narrowing of the pharynx on expiration Medicine. J Dent Sleep Med. 2014; 1(1): 39-50. Web site. http:// occurs during central hipocapnic hypopnea, supporting the www.aadsm.org/resources/pdf/consesusReport.pdf. Accessed concept that the presence of flow limitation by itself cannot be December 11, 2016.
18-20 used to distinguish between obstructive and central hypopnea.
9. Singh GD, Keropian B, Pillar G. Effects of the full breath We consider that scoring central and mixed events solution appliance for the treatment of obstructive sleep apnea:A in polysomnography is important not only in the baseline preliminary study. Cranio. 2009; 27(2): 109-117. doi: 10.1179/ assessment of sleep-related breathing disorders, but it should crn.2009.017 also be taken into account by the criteria used to estimate the therapies success.
10. Ngiam J, Kyung HM. Microimplant-based mandibular advancement therapy for the treatment of snoring and obstructive More studies are needed to better evaluate and clarify sleep apnea: A prospective study. Angle Orthod. 2012; 82(6): the relationship between obstructive, central and mixed events 978-984. doi: 10.2319/071311-449.1 and the impact of OA on the treatment of these sleep-related respiratory events.
11. Dort L, Remmers J. A combination appliance for obstructive sleep apnea: The effectiveness of mandibular advancement and CONFLICTS OF INTEREST tongue retention. J Clin Sleep Med. 2012; 8(3): 265-269. doi: 10.5664/jcsm.1910 The authors declare that they have no conflicts of interest.
12. Farrow SJ. Successful treatment of central sleep apnea