Obstrüktif Uyku Apne Sendromu Tedavisinde Diş Hekimliğinin Rolü
Özet
Obstrüktif Uyku Apne Sendromu (OUAS), uykuda solunum durması veya azalmasıyla karakterize, yetişkin popülasyonun %2 ila %4'ünü etkileyen yaygın bir hastalıktır. Diş hekimleri; retrognati, yüksek kemerli damak ve bruksizm gibi kraniyofasiyal ve orofaringeal risk faktörlerini tarayarak, hastaları uzman hekimlere yönlendirerek ve oral aparey tedavisi sunarak süreçte kritik bir rol oynarlar. OUAS tedavisinde Sürekli Pozitif Havayolu Basıncı (CPAP) en etkili yöntemlerden biri olsa da cerrahi müdahaleler ve kişiye özel ağız içi apareyler (OA) de önemli alternatiflerdir. Cerrahi seçenekler arasında Maksillomandibular İlerletme (MMA) %96 civarı başarı oranıyla öne çıkarken, invaziv yapısı nedeniyle genellikle son çare olarak değerlendirilir. Ağız içi apareyler ise Dili Önde Tutan (TRD) ve Mandibulayı Öne İlerleten (MRD) apareyler olarak ikiye ayrılır; MRD'lerin horlamayı azaltmada ve tolere edilmede TRD'lere kıyasla daha başarılı olduğu gösterilmiştir. OA'lerin gecelik kullanım süresi CPAP'tan daha uzun olabilmektedir ancak TME ağrısı ve tükürük artışı gibi komplikasyon riskleri nedeniyle hastaların düzenli takibi ve polisomnografi çalışmalarının tekrarlanması gereklidir. Sonuç olarak, OUAS tedavisinde multidisipliner bir yaklaşım benimsenmeli, hastanın durumuna ve tercihine göre en uygun tedavi planlanmalıdır.
Obstructive Sleep Apnea Syndrome (OSAS) is a prevalent disorder characterized by cessation or reduction of airflow during sleep, affecting 2% to 4% of the adult population. Dentists play a critical role in managing OSAS by screening for craniofacial and oropharyngeal risk factors—such as retrognathia, high-arched palate, and bruxism—referring patients to sleep specialists, and providing oral appliance therapy. While Continuous Positive Airway Pressure (CPAP) remains highly effective, surgical interventions and custom oral appliances (OA) serve as crucial treatment alternatives. Among surgeries, Maxillomandibular Advancement (MMA) yields a 96% success rate but is considered a last resort due to its invasive nature. Oral appliances are categorized into Tongue Retaining Devices (TRD) and Mandibular Repositioning Devices (MRD), with MRDs demonstrating superior success in reducing snoring and achieving better compliance than TRDs. Although OAs often exhibit longer nightly adherence than CPAP, they carry risks of complications like TMJ pain and increased salivation, necessitating systematic follow-ups and repeat polysomnography. Consequently, managing OSAS requires a multidisciplinary framework where treatment strategies are tailored entirely to the patient's severity and preference.
Referanslar
Mansukhani MP, Kolla BP, Wang Z, et al. Effect of Varying Definitions of Hypopnea on the Diagnosis and Clinical Outcomes of Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis. J Clin Sleep Med. 2019;15(5):687-696. doi:10.5664/jcsm.7750
Westchester, IL. (2005). American Academy of Sleep Medicine. International classifi¬cation of sleep disorders, (2nd Edition): Diagnostic and coding manual. American Academy of Sleep Medicine..
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014. doi:10.1093/aje/kws342
Mohammadieh A, Sutherland K, Cistulli PA. Sleep disordered breathing: management update. Intern Med J. 2017;47(11):1241-1247. doi:10.1111/imj.13606
Strauss RS, Browner WS. Risk for obstructive sleep apnea. Ann Intern Med. 2000;132(9):758-759. doi:10.7326/0003-4819-132-9-200005020-00015
Stansbury RC, Strollo PJ. Clinical manifestations of sleep apnea. J Thorac Dis. 2015;7(9):E298-E310. doi:10.3978/j.issn.2072-1439.2015.09.13
Lopes TDVC, Borba ME, Lopes RDVC, et al. Eating Late Negatively Affects Sleep Pattern and Apnea Severity in Individuals With Sleep Apnea. J Clin Sleep Med. 2019;15(3):383-392. Published 2019 Mar 15. doi:10.5664/jcsm.7658
Sutherland K, Keenan BT, Bittencourt L, et al. A Global Comparison of Anatomic Risk Factors and Their Relationship to Obstructive Sleep Apnea Severity in Clinical Samples. J Clin Sleep Med. 2019;15(4):629-639. Published 2019 Apr 15. doi:10.5664/jcsm.7730
Okeson JP, de Leeuw R. Differential diagnosis of temporomandibular disorders and other orofacial pain disorders. Dent Clin North Am. 2011;55(1):105-120. doi:10.1016/j.cden.2010.08.007
Remmers JE, Topor Z, Grosse J, et al. A Feedback-Controlled Mandibular Positioner Identifies Individuals With Sleep Apnea Who Will Respond to Oral Appliance Therapy. J Clin Sleep Med. 2017;13(7):871-880. Published 2017 Jul 15. doi:10.5664/jcsm.6656
Lavigne GJ, Herrero Babiloni A, Beetz G, et al. Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea. J Dent Res. 2020;99(1):26-35. doi:10.1177/0022034519885644
Ramar K, Dort LC, Katz SG, 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(7):773-827. Published 2015 Jul 15. doi:10.5664/jcsm.4858
Almoznino G, Benoliel R, Sharav Y, et al. Sleep disorders and chronic craniofacial pain: Characteristics and management possibilities. Sleep Med Rev. 2017;33:39-50. doi:10.1016/j.smrv.2016.04.005
Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):714–755. doi:10.1542/peds.2012-1672
Yoshida K. Oral device therapy for the upper airway resistance syndrome patient. J Prosthet Dent. 2002;87(4):427-430. doi:10.1067/mpr.2002.123228
Prinsell JR. Maxillomandibular advancement surgery for obstructive sleep apnea syndrome. J Am Dent Assoc. 2002;133(11):1489-1540. doi:10.14219/jada.archive.2002.0079
Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29(2):244-262. doi:10.1093/sleep/29.2.244
Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. American Sleep Disorders Association. Sleep. 1995; 18(6): 511-513. doi:10.1093/sleep/18.6.511
Marklund M, Verbraecken J, Randerath W. Non-CPAP therapies in obstructive sleep apnoea: mandibular advancement device therapy. Eur Respir J. 2012;39(5):1241-1247. doi:10.1183/09031936.00144711
Lazard DS, Blumen M, Lévy P, et al. The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome. J Clin Sleep Med. 2009;5(5):431-438.
Johal A, Battagel JM. Current principles in the management of obstructive sleep apnoea with mandibular advancement appliances. Br Dent J. 2001;190(10):532-536. doi:10.1038/sj.bdj.4801025
Barthlen GM, Brown LK, Wiland MR, Sadeh JS, Patwari J, Zimmerman M. Comparison of three oral appliances for treatment of severe obstructive sleep apnea syndrome. Sleep Med. 2000;1(4):299-305. doi:10.1016/s1389-9457(00)00030-7
Sarı E, Liebermann L, Karaçay Ş. Oral Horlama ve Obstrüktif Uyku Apnesinde Kullanılan Apareyler. Türk Ortodonti Dergisi 2006; 19: 181-196.
Kato J, Isono S, Tanaka A, et al. Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep-disordered breathing. Chest. 2000;117(4):1065-1072. doi:10.1378/chest.117.4.1065
Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013;187(8):879-887. doi:10.1164/rccm.201212-2223OC
Nadal N, de Batlle J, Barbé F, et al. Predictors of CPAP compliance in different clinical settings: primary care versus sleep unit. Sleep Breath. 2018;22(1):157-163. doi:10.1007/s11325-017-1549-7
Varga AW, Mokhlesi B. REM obstructive sleep apnea: risk for adverse health outcomes and novel treatments. Sleep Breath. 2019;23(2):413-423. doi:10.1007/s11325-018-1727-2
Cunha TCA, Guimarães TM, Schultz TCB, et al. Predictors of success for mandibular repositioning appliance in obstructive sleep apnea syndrome. Braz Oral Res. 2017;31:e37. doi:10.1590/1807-3107BOR-2017.vol31.0037
Op de Beeck S, Dieltjens M, Verbruggen AE, et al. Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study. J Clin Sleep Med. 2019;15(8):1089-1099. doi:10.5664/jcsm.7796
Sutherland K, Ngiam J, Cistulli PA. Performance of Remotely Controlled Mandibular Protrusion Sleep Studies for Prediction of Oral Appliance Treatment Response. J Clin Sleep Med. 2017;13(3):411-417. Published 2017 Mar 15. doi:10.5664/jcsm.6492
