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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 57-60

Association of obstructive sleep apnea with edentulism: A retrospective analysis


1 Department of Chest and TB, GMC Rajouri, Rajouri, India
2 Department of Prosthodontics, IGGDC, Jammu, Jammu and Kashmir, India
3 Private practitioner, Jammu, Jammu and Kashmir, India
4 Department of Prosthodontics, Kalka Dental College and Hospital , Meerut, Uttar Pradesh, India
5 Department of Prosthodontics, Government Dental College, Dibrugarh, Assam, India
6 Department of Prosthodontics, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India

Date of Submission03-Aug-2022
Date of Acceptance10-Aug-2022
Date of Web Publication29-Sep-2022

Correspondence Address:
Dr. Rimsha Ahmed
Department of Prosthodontics, IGGDC, Jammu, Jammu and Kashmir 181152
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_15_22

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  Abstract 

Aim of the Study: There have been very limited studies in the recent past regarding the correlation between the complete loss of teeth and the severity of obstructive sleep apnea syndrome (OSAS). The assessment of the association between the status of the dentition (completely edentulous vs dentulous) and the severity of OSAS was the aim of this study. Materials and Methods: A retrospective, cohort study of completely edentulous and dentulous subjects suffering from OSAS was planned with the primary predictor variable being the status of the dentition (dentulous vs edentulous). Apnea–hypopnea index (AHI) was used to measure the severity of OSAS, which was used as the primary outcome variable. Unpaired T test and chi-square test were used to assess the data. Results: The total number of subjects incorporated in this study was 56. More severe OSAS was seen in completely edentulous subjects as compared to subjects with natural dentition, with a statistically significant difference for AHI between these groups. Conclusion: When compared, more severe OSAS was seen in completely edentulous subjects, within the limits of the study.

Keywords: Edentulism, obstructive apnea, sleep study


How to cite this article:
Khan MZ, Ahmed R, Rehman B, Sethi S, Hazarika P, Swarnakar A. Association of obstructive sleep apnea with edentulism: A retrospective analysis. Int J Oral Care Res 2022;10:57-60

How to cite this URL:
Khan MZ, Ahmed R, Rehman B, Sethi S, Hazarika P, Swarnakar A. Association of obstructive sleep apnea with edentulism: A retrospective analysis. Int J Oral Care Res [serial online] 2022 [cited 2022 Dec 10];10:57-60. Available from: https://www.ijocr.org/text.asp?2022/10/3/57/357312




  Introduction Top


Obstructive sleep apnea syndrome (OSAS) is a disorder whereby nocturnal breathing cessation occurs repeatedly due to upper airway collapse, which eventually results in decreased oxygen saturation.[1] In long term, its association with severe symptoms such as cardiovascular morbidity and mortality has been observed.[2] The severity of OSAS is affected by a number of factors including the loss of teeth. Complete edentulism leads to a reduction in the lower facial height, which further leads to morphologic changes affecting the upper airway and respiration. All these factors could further worsen OSAS because of anatomical and functional modification of the airway in relation to pharynx and tongue.[3] Because of limited data on the relationship of OSAS and complete edentulism, the influence of the loss of teeth on OSAS is not clear. So the aim of this study was to assess the affect of status of dentition on the severity of OSAS. This study was designed to determine whether the dentition plays a role in the severity of OSAS or not.

The specific aim and objectives of the present study were: (1) to assess the relationship of the status of dentition on the severity of obstructive sleep apnea (OSA), (2) to analyze the relationship between oxygen desaturation index (ODI) and apnea–hypopnea index (AHI), and (3) to analyze the correlation between the basal metabolic index (BMI) and AHI. It was hypothesized that no difference exists in the degree of the severity of OSA in completely edentulous and dentulous subjects (null hypothesis).


  Materials and Methods Top


A retrospective, comparative, cohort study of completely edentulous subjects and age group and gender matched dentulous subjects was developed. Data were obtained from a sleep study center (level 3) in northern India, where subjects had been referred by doctors for polysomnography by trained technical staff, between June 2015 and June 2021. Among the data of 476 patients screened, 56 patients with nearly similar age group and gender but with a difference in the status of dentition were selected. Group 1 comprised of dentate subjects with ≥10 occluding teeth, whereas group 2 had completely edentulous subjects. All procedures performed in the study were conducted in accordance with the ethics standards given in 1964 Declaration of Helsinki, as revised in 2013. The study proposal was submitted for approval and clearance was obtained from the ethical committee of our institution. A written informed consent was obtained from each participant.

Inclusion criteria for the study

  • (1)Subjects in the age group of 60–80 years with at-home overnight polysomnogram–confirmed OSAS were included in the study for both the groups (AHI > 5)


  • (2)In addition, age and gender–matched dentulous adult subjects (with ≥10 occluding teeth) were selected for the study.


Exclusion criteria for the study

  • (1)Insufficient information on the patient’s medical record


  • (2)More than 10 occluding teeth


  • (3)Denture wearers who wear denture during night.


Sample size

The formula n = (DEFF × Np[1 − p])/(d2/Z21 − α/2 × [N − 1] + p × [1 − p]) was used to calculate the sample size for the study where p is the prevalence of OSAS among Indian population. To achieve a power of 95%, with an error of 0.05, a sample size of 28 subjects per group was finalized (N = 56).

Statistical analysis

After thorough screening, the collected data were entered into MS Excel spreadsheet. SPSS (Statistical Package for Social Sciences) version 20 was used to carry out the analysis. For continuous variables and frequencies, the data were presented as mean and standard deviation, whereas the presentation of categorical variables was done as percentages. The comparison of continuous variables was done using unpaired T test and one-way ANOVA. In case of categorical data, comparison was done using chi-square test. P value of <0.05 was considered as significant.


  Results Top


Fifty-six subjects in total were included in this study and were divided into two groups: group I included dentulous subjects, whereas completely edentulous subjects were included in group 2. The subjects were age group and gender matched to reduce the bias. No statistically significant differences (P > 0.05) were noted in the variables such as weight, height, and BMI when the two groups were compared [Table 1]. It was found that the severity of OSAS was more in completely edentulous subjects as compared to the dentulous subjects, with highly statistically significant differences in the mean AHI (dentulous: 14.107 ± 13.4601; edentulous: 45.454 ± 17.8412; P = 0.000) and ODI (dentulous: 14.775 ± 12.45 vs edentulous: 43.979 ± 13.57; P = 0.00) between the two groups [Table 2] and [Table 3]. On comparing the mean of AHI to the BMI of the patients, a significant correlation (P < 0.05) was seen [Table 4], [Figure 1]. Thus, it can also be interpreted that as the BMI of the patients increases so does the AHI, resulting in an increased severity of OSAS. Chi-square test was used to analyze the association between the status of dentition and the severity of OSAS within the two groups, and it was found to be significant [Figure 2]. It was also noted that among the doctors who had referred the patients for the sleep study analysis, 35.71% of referrals for sleep study were done by chest physicians, 32.14% by ENT specialists, 19.64% by physicians, 8.9% by general practitioners, and just 4% cases were reported by dentists.
Table 1: Comparison between the variables of both the groups

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Table 2: Comparison between the AHI and weight

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Table 3: Comparison between ODI and weight

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Table 4: Comparison between AHI and BMI

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Figure 1: Comparison between BMI and AHI. AHI = apnea–hypopnea index, BMI = basal metabolic index

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Figure 2: Association between the status of dentition and severity of OSAS. OSAS = obstructive sleep apnea syndrome. **P value = significant

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  Discussion Top


The relationship of edentulism and the severity of OSAS has been a topic of limited research in the recent past. The loss of teeth remains a common condition in elderly patients despite advancements in primary dental care. Edentulism is an irreversible condition, which is enfeebling and is described as the “final marker of disease burden for oral health.”[4] Following edentulism, a plethora of changes occur that include a reduction in the vertical dimension of occlusion,[5],[6],[7],[8] decrease in the lower facial height[5],[6],[7],[8] and anterosuperior rotation of the mandible,[9],[10] and changes in the mandibular position, which further lead to various esthetic changes. In addition, a decrease in neuromuscular coordination[11] and upper airway collapse and alterations in its size, elasticity, and function[5],[6],[7],[8] along with a decreased retropharyngeal space contribute to the OSA development. This study was designed to get answer to the question—Does dentition plays a role in the severity of OSAS?

Patients with the same age group and gender were selected to reduce the bias because it has been reported that the severity of OSAS in males is more than that of females.[12] Accurate evaluation of factors such as edentulism can be allowed only by controlling for the known risk factors for any disease (age and gender). According to this study, a significant difference (P < 0.05) between AHI and ODI of dentulous and edentulous patients was seen. Also, there was a positive correlation between mean AHI and BMI among dentulous as well as edentulous patients, but there was no significant difference among the two groups. Thus, it could be interpreted that the severity of OSAS increases with the loss of teeth. The results of this study are in accordance with the researches conducted by Gassino et al.[13] and Bucca et al.[10] as well. Also, with the increase in BMI of the subjects, the severity of OSAS showed an increasing trend. Özdilekcan et al.[14] reported the same, and according to the study conducted by them, higher BMI values were found to be correlated with the diagnosis and severity of OSA and reduced sleep efficiency. An interesting finding that was seen among all the referrals made by doctors for polysomnography was that only 4% were made by dentists. This might be due to a lack of awareness among dentists regarding the diagnosis of OSAS. Various awareness programs are the need of the hour to make them familiar with the condition because they have an important role in its diagnosis and treatment.

For treating OSAS, the first-line therapy according to the the current guidelines (nonsurgical) includes lifestyle mod ifications, positional therapy, and continuous positive airway pressure (nasally applied). The second line of treatment includes oral appliances or surgical approaches based on the etiology and severity.[15] Oral appliances are generally not indicated for completely edentulous patients, because teeth are required to support and retain them.[16] In such cases, CPAP generally becomes the treatment of choice. Discomfort with the mask, nasal congestion, and difficulty in adaptation to the pressure have been identified disadvantages in CPAP therapy.[17],[18] According to Petit et al., oral appliance therapy is contraindicated because of its limitations in relation to the status of dentition in about 34% of OSA cases.[19] For the treatment of more severe cases of OSA, other options include maxillomandibular advancement and soft-tissue surgery.

Limitations

The limitations of this study are the same as inherent to a retrospective study including data bias, selection bias, information bias, and Berkson’s bias. Also, sample size was limited in the present study. In addition, the data were collected using a home PSG system (type III home sleep apnea testing), which could further lead to inaccuracies.


  Conclusions Top


Within the limitations of the study, following conclusions were drawn:

  1. There is a significant correlation of the AHI in dentulous and completely edentulous patients within the same age group and gender. Thus, it can be concluded that edentulism results in an increase in the severity of OSAS.


  2. Also with the increase in the severity of the OSAS, ODI also increases.


  3. As the BMI increases so does the severity of OSAS.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP Pathophysiology of sleep apnea. Physiol Rev 2010;90:47-112.  Back to cited text no. 1
    
2.
Xie A, Patz DS, Wang D Physiology in medicine: Obstructive sleep apnea pathogenesis and treatment—Considerations beyond airway anatomy. J Appl Physiol (1985) 2014;116:3.  Back to cited text no. 2
    
3.
Okşayan R, Sökücü O, Uyar M, Topçuoğlu T Effects of edentulism in obstructive sleep apnea syndrome. Niger J Clin Pract 2015;18:502-5.  Back to cited text no. 3
    
4.
Emami E, de Souza RF, Kabawa M, Feine JS The impact of edentulism on oral and general health. Int J Dent 2013;2013:1-8.  Back to cited text no. 4
    
5.
Tripathi A, Bagchi S, Singh J, Tripathi S, Gupta NK, Arora V Incidence of obstructive sleep apnea in elderly edentulous patients and the possible correlation of serum serotonin and apnea-hypopnea index. J Prosthodont 2019;28:e843-8.  Back to cited text no. 5
    
6.
Marcus PA, Joshi A, Jones JA, Morgano SM Complete edentulism and denture use for elders in New England. J Prosthet Dent 1996;76:260-6.  Back to cited text no. 6
    
7.
Athanasiou AE, Papadopulos MA, Mazaheri M, Lagoudakis M Cephalometric evaluation of pharynx, soft palate, adenoid tissue, tongue and hyoid bone following the use of mandibular repositioning appliance in obstructive sleep apnea patient. Int J Adult Orthod Orthogn Surg 1994;9:273-83.  Back to cited text no. 7
    
8.
deBerry-Borowiecki B, Kukwa A, Blanks RH Cephalometric analysis for diagnosis and treatment of obstructive sleep apnea. Laryngoscope 1988;98:226-34.  Back to cited text no. 8
    
9.
Bucca C, Carossa S, Pivetti S, Gai V, Rolla G, Preti G Edentulism and worsening of obstructive sleep apnoea. Lancet 1999;353:121-2.  Back to cited text no. 9
    
10.
Bucca C, Cicolin A, Brussino L, Arienti A, Graziano A, Erovigni F, et al. Tooth loss and obstructive sleep apnoea. Respir Res 2006;7:8.  Back to cited text no. 10
    
11.
Cistulli P, Sullivan CE Pathophysiology of sleep apnea. In: Sullivan CE, Sanders NA, editors. Sleep and Breathing. 2nd ed. New York: Marcel Dekker; 1994. p. 405-88.  Back to cited text no. 11
    
12.
Kim SW, Taranto-Montemurro L When do gender differences begin in obstructive sleep apnea patients? J Thorac Dis 2019;11:1147-9.  Back to cited text no. 12
    
13.
Gassino G, Cicolin A, Erovigni F,Carossa S, Preti G Obstructive sleep apnea, depression, and oral status in elderly occupants of residential homes. Int J Prosthodont 2005;18:316-22.  Back to cited text no. 13
    
14.
Özdilekcan Ç, Özdemir T, Türkkanı MH, Sur HY, Katoue MG The association of body mass index values with severity and phenotype of sleep-disordered breathing. Tuberk Toraks 2019;67:265-71.  Back to cited text no. 14
    
15.
Epstein LJ, Kristo D, Strollo PJJr, Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-76.  Back to cited text no. 15
    
16.
Ferguson KA The role of oral appliance therapy in the treatment of obstructive sleep apnea. Clin Chest Med 2003;24:355-64.  Back to cited text no. 16
    
17.
Rosenberg R, Doghramji P Optimal treatment of obstructive sleep apnea and excessive sleepiness. Adv Ther 2009;26:295-312.  Back to cited text no. 17
    
18.
Zozula R, Rosen R Compliance with continuous positive airway pressure therapy: Assessing and improving treatment outcomes. Curr Opin Pulm Med 2001;7:391-8.  Back to cited text no. 18
    
19.
Petit FX, Pépin JL, Bettega G, Sadek H, Raphaël B, Lévy P Mandibular advancement devices: Rate of contraindications in 100 consecutive obstructive sleep apnea patients. Am J Respir Crit Care Med 2002;166:274-8.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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