SMASHED FACE SYNDROME: AN UNDESIRED SIDE EFFECT OF CPAP. CHEST ARTICLE DETAILS CRANIOFACIAL CHANGES WITH CPAP USE.

Sleep apnea is a serious and dangerous disorder that can cause a wide variety of illness and dysfunction. CPAP is considered the Gold Standard of treatment for sleep apnea and the first line treatment for severe sleep apnea. For mild to moderate sleep apnea cpap and oral appliances (http://www.ihatecpap.com) are considered the first line treatment.

Numerous studies attest to the efficacy of Continuous Positive Airway Presssure (CPAP) for treating sleep apnea. Unfortunately, there are numerous articles relating to CPAP failure due to non-compliance. A recent study showed 60% of patients abandon CPAP therapy entirely and that even among patients who utilize CPAP average compliance is only 4-5 hours a night 4-5 nights a week.

Approximately 25% of CPAP patients love their CPAP from the start of treatment and their compliance is very high, often reporting using CPAP all night every, every night.

It is these patients who are most likely to have Smashed Face Syndrome that was reported in October Chest in an article by Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA titled “Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea” (see abstract below).

The article details changes to the position of the bones of the jaw and cranium and to changes in tooth position that occur in as little as 2 years of CPAP usage. The article states that “After nCPAP use, cephalometric variables demonstrated a significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity”

In simple English it means that the upper jaw was pushed backward and the upper teeth pushed backward changing the angle they come out of the jaws. The lower jaw and chin were also pushed backward and there was less freedom of movement available between the upper and lower jaws. These same changes are often seen in patients with chronic headaches, migraines and TMJ disorders (http://www.ihateheadaches.org). MaxiiloMandibular Advancement (MMA) is the most effective surgery for sleep apnea. MMA surgically corrects sleep apnea by moving the upper and lower jaws forward, exactly the opposite of what happens in Smashed Face Syndrome. It has been discussed that patients can become “addicted” to CPAP. This may be due to physiologic responses of the pharyngeal reflexes but it might also be due to an anatomical worsening of the underlying jaw conditions that lead to sleep apnea initially.

These changes should not cause patients quit CPAP therapy that can be life saving but the use of intra-oral appliances to prevent these changes should be considered. It is absolutely essential that patients be informed of these orthopedic and orthodontic changes that can occur. Dentists have been treating patients with oral appliances for many years and inform their patients of orthodontic and dental changes that can occur. In contrast to CPAP the change that occur with usage of an oral appliance to treat sleep apnea actually decrease the risk of sleep apnea. Studies have shown no long term TMJ (Temporomandibular Joint) problems associated with use of Oral Appliances to treat sleep apnea and snoring. Dental and Orthopedic change definitely occur with long-term use but many patients consider the changes of no consequence or even as favorable.

CPAP is considered the first choice of treatment for patients with severe sleep apnea. Oral Appliances are a first line of treatment for mild to moderate sleep apnea but are considered an alternative to CPAP for severe sleep apnea when patients do not tolerate CPAP. The National Heart Lung and Blood Institute (NHLBI) considers sleep apnea to be a TMJ disorder in their report “CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS”. The entire report can be viewed @ http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf.

It is essential that patients using CPAP or Oral Appliances be aware of orthopedic and orthodontic changes that can occur from the use of either modality. Consideration of alternating between therapies is one option. There is also the ability to use combination therapy. The TAP-PAP appliance uses the upper jaw to retain the CPAP mask that decreases and/or eliminates the potential for retropositioning of the maxilla. Combination therapy can lower CPAP pressures. The proble remains 60% of all CPAP users reject the device and seek out CPAP Alternative.

It has been reported to this author that Dr Colin Sullivan, the Australian who invented CPAP actually utilizes an oral appliance to treat his own sleep apnea. I have heard this from numerous sources but I have not received confirmation of this fact from Dr Sullivan so it can only be considered a rumor at this time.

What is the best sleep apnea treatment? The best sleep apnea treatment eliminates the problem with a minimum of negative side effects. For patients with severe sleep apnea and who tolerate CPAP the best treatment is often CPAP. For the majority of patients who do not tolerate or HATE CPAP (http://www.ihatecpap.com) oral appliances may be the best sleep apnea treatment. For patients who do not tolerate CPAP or Oral Appliances Surgery may be the best sleep apnea treatment.

Soft palate surgery is rarely if ever the best treatment. UP# surgery or Uvulopalatopharyngealplasty has high morbidity and low effectiveness. Variations such as Pillars, Snoreplasty, Somnoplasty of soft palate or LAUP or Laser Assisted Uvuloplasty are rarely effective in treating sleep apnea.

The best sleep apnea surgeries are usually Maxillomandibular advancement or genioglossal advancement and tongue reduction surgeries.

These are all major surgical procedures but can be the best sleep apnea treatment for some patients.

The quote “There is no disease or disorder known to man that can’t be made worse by sticking a knife in it ” is a warning to all patients considering surgery to evaluate all the possible consequences befor doing surgery. It does not mean avoid surgery but proceed with caution, ask questions and get second opinions before proceeding with surgery.

Surgery to correct deviated septums or reduce obstructive turbinates are relatively low risk surgical procedures that almost always improve the quality of patients lives. They usually will not cure sleep apnea but will improve treatment with other modalities.

Weight loss and/or positional therapy to treat sleep apnea is probably the best sleep apnea treatment for many patients and are often used in conjunction with other treatments.

Regardless of the treatment patients chose to fit their lifestyles it is essential that sleep studies be utilized to ensure treatment efficacy.

Dr Shapira treats sleep apnea and snoring at his general dental practice, Delany Dental Care Ltd in Gurnee, Illinois and at offices of Chicagoland Dental Sleep Medicine Associates in Skokie and Schaumburg. Contact Dr Shapira toll free at 1-8-NO-PAP-MASK OR AT 1-800-TM-JOINT.

Chest. 2010 Oct;138(4):870-4. Epub 2010 Jul 8.
Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea.
Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA.

Department of Oral Health Sciences, The University of British Columbia, Vancouver, BC, Canada. htsuda@dent.kyushu-u.ac.jp
Abstract
BACKGROUND: Many patients with obstructive sleep apnea (OSA) use nasal continuous positive airway pressure (nCPAP) as a first-line therapy. Previous studies have reported midfacial hypoplasia in children using nCPAP. The aim of this study is to assess the craniofacial changes in adult subjects with OSA after nCPAP use.

METHODS: Forty-six Japanese subjects who used nCPAP for a minimum of 2 years had both a baseline and a follow-up cephalometric radiograph taken. These two radiographs were analyzed, and changes in craniofacial structures were assessed. The cephalometric measurements evaluated were related to face height, interarch relationship, and tooth position.

RESULTS: Most of the patients with OSA were men (89.1%), and the mean baseline values for age, BMI, and apnea-hypopnea index (AHI) were 56.3 ± 13.4 years, 26.8 ± 5.6 kg/m(2), and 42.0 ± 18.6/h. The average duration of nCPAP use was 35.0 ± 6.7 months. After nCPAP use, cephalometric variables demonstrated a significant retrusion of the anterior maxilla, a decrease in maxillary-mandibular discrepancy, a setback of the supramentale and chin positions, a retroclination of maxillary incisors, and a decrease of convexity. However, significant correlations between the craniofacial changes, demographic variables, or the duration of nCPAP use could not be identified. None of the patients self-reported any permanent change of occlusion or facial profile.

CONCLUSION: The use of an nCPAP machine for > 2 years may change craniofacial form by reducing maxillary and mandibular prominence and/or by altering the relationship between the dental arches.

PMID: 20616213 [PubMed – indexed for MEDLINE]