By Mark Collins, DDS and James Collins
Titration is often the most difficult component of dental sleep medicine and the methods used to verify titration vary between practitioners. However, the end results of titration should maximize the relief of subjective symptoms while striving to optimize objective outcomes. Epworth and Berlin Sleepiness Scales help practitioners assess and relieve subjective symptoms while pulse oximeters and home sleep testers (HST) help practitioners assess and optimize objective outcomes. Yet, most type III home sleep testers and pulse oximeters do not detect sleep patterns or central sleep apneas. This case, however, used a type III home sleep tester that features Respiratory Inductive Plethysmography (RIP) belts, which allowed us to differentiate between obstructive and central sleep apneas.
Introduction and History
This case regards a 52-year-old Caucasian man who was referred to our office by an American Academy of Sleep Medicine (MSM) board-certified sleep medicine physician . The patient is 5’11” and weighs 195 pounds. He has a 16 inch neck size and his Epworth Sleepiness Scale is 8. The patient’s chief complaints are snoring, daytime sleepiness, trouble falling asleep and that he stops breathing while sleeping (according to his partner). Due to continuous positive airway pressure (CPAP) restricting movements, the disturbing noise from CPAP devices, claustrophobia, and general discomfort while wearing CPAP devices, the patient was deemed CPAP intolerant. His polysomnogram (PSG) from a sleep lab, read by an AASM board-certified physician, showed a reduced sleep deficiency of 36 percent, a rapid eye movement (REM) latency of 320 minutes, and an obstructive sleep apnea (OSA) with an apnea hypopnea index (AHI) of 37. Respiratory disturbances resulted in moderate to severe oxygen desaturation, which caused the Sa02 to be 77 percent at its lowest. No periodic limb movements during sleep or arrhythmias were recorded. A split night study was performed in order to test the patient on CPAP use, however, no central sleep apneas were found. The patient has a medical history of congestive heart failure, uses a pacemaker and owns a defibulator. He also has low blood pressure. The patient reports all other aspects of his health to be normal. The medications used by the patient at the time of treatment were: Corg 37.5 mg twice a day, Spironolactone 25 mg once a day, Amiodarone 100 mg once a day, Zestril 10 mg once a day, Digoxin 0.125 once a day, Metanx 75 mg twice a day, Simvastiatin 10 mg once a day, Pradaxa 75 mg twice a day, Furosemide 40 mg every other day, KlOR-con 10 mg every other day and Mag-64 twice a day. The patient has no known allergies and does not smoke, drink alcohol or consume caffeine. Furthermore, the patient has no family history of sleep apnea, heart problems, or diabetes.
The initial exam revealed the patient’s blood pressure to be 132/78 mmHg and his pulse to be 56 bpm. The patient’s body mass index (BMI) was 26 kg/ m2 and his adjusted neck circumference was 42 cm. All four of the patient’s wisdom teeth had been removed more than 20 years ago. Additionally, the patient has a class 1 occlusion with a 2 mm anterior overjet and a 2 mm anterior overbite. The patient’s periodontal health is good and he has no oral pathologies or caries. However, he does suffer from mild pitting on his molar occlusals and abfractions on his maxillary and mandibular premolars. Furthermore, the patient also has a mandibular tori, a scalloped tongue with a medium level and a class 1 mallampati with no tonsils present. The patient has no airway problems, and an acoustic airway reflection rhinometry shows a clear airway. The patient does not suffer from temporomandibular joint (TMJ) or range of motion complications and no organ complications were found. The patient is alert and articulate, and appears in good health with a healthy skin color and temperature. Panoramic x-ray revealed no pathologies and the cephalogram revealed no abnormalities.
A Herbst appliance manufactured by Gergen’s Orthodontic Lab was chosen for the patient, because he is predominantly a mouth breather and, as a Medicare recipient, he required a Medicare-approved appliance. Additionally, a morning aligner was made with the Patterson Dental TAP® AM Aligner. The patient was instructed on the use and care of the appliances and was able to insert and remove the appliance himself. In a follow-up
phone call made 24 hours later, the patient reported to be following the instructions and was using the device with no complications. The patient experienced no teeth, gum, or jaw discomfort, and was able to sleep for eight hours while wearing the appliance. Each week for the next four weeks the patient returned to our office and during each visit we perform a titration of four half turns forward until the patient said he was feeling better. The patient’s snoring had stopped, but he did not feel refreshed. So, I decided to run a home sleep test to see if there were any objective improvements to his condition.
We used an Embletta® Gold Type III home sleep testing (HST) device. This appliance was chosen for its RIP belts, which distinguish obstructive sleep apneas from central sleep apneas. The patient returned the next morning and reported a normal night’s sleep, but he still felt tired. After considering the large amount of central sleep apneas in the test results, we advised the patient to attend a new PSG, but he refused to. So, we ran an additional HST to ensure the first test was not complicated by a first pass effect or faulty tester.The HST results showed an overall AHI of 24.2 with 100 apneas and 52 hypopneas. There were 4 obstructive apneas, 70 central apneas and 26 mixed apneas. Overall the obstructive AHI was 0.6, the central AHI was 11.2, and the mixed AHI was 4.1. According to The Apnea- Desaturation Relation, the mean oxygen saturation was 93.4 percent and the lowest oxygen saturation was 79 percent. There were 73 episodes of snoring, which has a total duration of 23.8 minutes. These results were recorded using the automatic scoring in the RemLogic software. No physician diagnosis of the scores was requested.
For the second HST, which we performed the next night, we used a different Embletta Gold tester. The test’s results showed an overall AHI of32.4 with 134 apneas: 4 obstructive, 91 cern:fal, 39 mixed and 34 hypopneas. The obstructive AHI was 0.8, the central AHI was 17.5, and the mixed AHI was 7.5. According to The Apnea Desaturation Relation, the mean oxygen saturation was 94.2 percent and the lowest oxygen saturation was 82 percent. This test was not scored or submitted to a physician.
Patient’s Progress and Outcome
The oral appliance titration treatment was stopped until a sleep physician or cardiac physician was involved. The patient’s sleep physician was consulted and he advised that the patient be referred to his cardiac physician immediately for a full cardiac workup and a sleep evaluation with a PSG. Since the patient’s cardiac physician is located in Loma Linda Medical Center, which is eight hours away from his home by car, the patient was encouraged to be under the care of the medical center’s sleep physician and cardiology departments. According to the most recent updates, the patient is suffering from congestive heart failure and his prognosis is poor. He is under the care of a cardiologist and sleep physician for his central sleep apnea and congestive heart failure.
This case has demonstrated that the use of a Type III HST that lacks the ability to distinguish between central and obstructive sleep apneas or the use of pulse oximetry can cause oral appliance therapy (OAT) to fail. Furthermore, treating a patient without distinguishing between central and obstructive sleep apneas can be detrimental to a patient’s health. Conversely, the use of a Type III HST with RIP bands allows the practitioner to recognize possible cardiac complications, which would not be recognized by most other testing devices. Although the patient l’iad a history of congestive heart failure, central sleep apneas were not suspected due to the patient’s prior PSG. However, the patient was found to have central sleep apneas, which led to the referral to the cardiologist and sleep physician. Therefore, this case shows the life-saving importance of using Type III HST’s with RIP-belts.
Further research needs to be performed in the distinguishing between central verses obstructive apneas during titration and Type III home sleep testing equipment’s abilities to find these differences. Also, Type III and IV testing on patients with a history of congestive heart failure accuracies in titration studies should be reviewed further
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Mark Collins , DDS, graduated from the University of Iowa 1997 and is a general dentist with a private practice in Fort Mohave, Ariz. Director of the only AADSM accredited dental facility in Arizona, Dr. Collins also currently serves on the Accreditation Committee of the AADSM .
James Collins is currently a student at the University of Arizona and is a freelance and technical writer.
This article was previously published in American Academy of Dental Sleep Medicine Dialogue ISSUE 3, 2013 pgs 24-26
No physician diagnosis of the scores was requested.
After considering the large amount of central sleep apneas in the test results, we advised the patient to attend a new PSG, but he refused to. So, we ran an additional HST to ensure the first test was not complicated by a first pass effect or faulty tester.
For the second HST, which we performed the next night, we used a different Embletta Gold tester. The test’s results showed an overall AHI of
32.4 with 134 apneas: 4 obstructive, 91 cern:fal, 39 mixed and 34 hypopneas. The obstructive AHI was 0.8, the central AHI was 17.5, and the mixed AHI was 7.5. According to The Apnea Desaturation Relation, the mean oxygen saturation was 94.2 percent and the lowest oxygen saturation was 82 percent. This test was not scored or submitted to a physician.
mean oxygen satuootion was 93.4 percent and the lowest oxygen saturation was 79 percent. There were 73 episodes of snoring, which has a total duration of 23.8 minutes. These results were recorded using the automatic scoring in the RemLogic software