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Compendium
March 2016
Volume 37, Issue 3

Diagnostic Technologies

Because some of the anatomic features that contribute to sleep-disordered breathing can be observed during an oral examination, dentists with training in dental sleep medicine can identify patients with the signs and symptoms of this condition. When signs of sleep-disordered breathing are discovered, asking questions about the patient’s sleep habits and sleep quality can confirm the need for diagnostic testing and referral to a board-certified sleep medicine physician.

Polysomnography

Polysomnography was originally the “go-to” method for diagnosing sleep apnea and sleep-disordered breathing. Although considered the most accurate approach for diagnosing patients with this condition, simpler and less complicated methods were needed to overcome the expense, labor intensity, and poorly tolerated instrumentation inherent with polysomnography.11

Portable Home Sleep Study

Portable home sleep studies gained in popularity as an alternative, largely because they can be performed at home and involve a less complicated procedure (Figure 1). Requiring less monitoring and well-tolerated by patients, portable home sleep studies have been shown to demonstrate high specificity and sensitivity for identifying patients with sleep apnea.11

When the diagnosis reveals moderate to severe sleep apnea and/or obstructive sleep apnea, further diagnostics and evaluation of maxillofacial, oropharyngeal, and upper airway anatomy are required. These additional diagnostics and evaluations help to identify the anatomical cause and extent of the obstruction, and guide dentists and sleep physicians in their decisions regarding the most appropriate treatment approach for the patient.

Radiographs and CBCT

Dental radiographs and cone-beam computed tomography (CBCT) play significant roles in assessing patients with sleep-disordered breathing, enabling more precise identification of the areas and extent of airway obstructions.8 In particular, 3-dimensional (3-D) CBCT images allow analysis of the airways and specific maxillofacial, oropharyngeal, and other anatomy that may be involved with sleep-disordered breathing. Considering that years of research have identified radiographically visible anatomical characteristics and obstructions in patients with sleep-disordered breathing, CBCTs in the dental practice can be a valuable screening and treatment planning tool.8

For example, attempts were made to identify upper airway abnormalities in patients with idiopathic obstructive sleep apnea. Cross-sectional analysis of cephalometric roentgenograms revealed that the patients studied had smaller mandibles and overall posterior displacement of the mandibular symphysis, and that there was a correlation between the number of apnea episodes and posterior displacement. This suggested a correlation between idiopathic obstructive sleep apnea and upper airway occlusion that is not visible during an oral examination.7

Similarly, cephalometric roentgenograms have been studied and shown to indicate the presence of small posterior airway space and inferiorly placed hyoid bone in patients with obstructive sleep apnea who required palatopharyngoplasty (PPP) in order to better identify the soft-tissue obstruction location.12 Additionally, other dentofacial features (eg, retrognathia, micrognathia, skeletal Class II, long soft palate, tonsillar hypertrophy, inferior hyoid bone position) of patients with obstructive sleep apnea have been identified and categorized through cephalometric evaluation and found to correspond to specific types of obstructive sleep apnea.13

In more recent years, studies have focused on the manner in which the use of CBCT scans could potentially lend greater precision to analyzing the maxillofacial and airway characteristics of patients with sleep-disordered breathing. However, more research and discussion are needed to confirm the full extent to which CBCTs can benefit dentists when collaborating with sleep physicians in the diagnosis, screening, and treatment planning of patients with sleep-disordered breathing.

Among the relevant research conducted, a 2009 study compared imaging information about nasopharyngeal airway size between lateral cephalometric headfilms and 3-D CBCT scans and found considerable variability in the airway volumes of patients with similar airways among the lateral headfilms, whereas the 3-D CBCT scans were found to be simple and effective for accurately analyzing the airway.5 Subsequently, CBCTs have been used to determine linear, volumetric, and cross-sectional airway area measurements in patients with sleep-disordered breathing, ultimately determining that the areas where most airway constriction occurs can vary, with the variation correlating in part to age and gender.14

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