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Volume 14 No. 04
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Accepted Papers





Case Reports

Tooth Movement Associated With CPAP Therapy

Benjamin T. Pliska, DDS, MS; Fernanda R. Almeida, PhD
Department of Oral Health Sciences, University of British Columbia Faculty of Dentistry, Vancouver, Canada

ABSTRACT

We report on a rarely documented side effect—tooth movement—associated with positive airway pressure therapy. A 64-year-old woman presented to an orthodontic practice for evaluation of unexplained tooth movement and spaces opening between her anterior teeth. The patient recently received a diagnosis of mild obstructive sleep apnea, for which she had been using continuous positive airway pressure (CPAP) delivered by a nasal pillows interface for the past 18 months. Follow-up questioning revealed that shifting of the teeth was first noticed in the months following the initiation of CPAP and the result of forward thrusting of the tongue during use. Following 12 months of orthodontic treatment, the malocclusion was corrected and teeth returned to their pretreatment positions. Unwanted tooth movement, although a minor sequela, can have a meaningful effect on quality of life. With improved awareness of this issue, the patient experience and ultimately adherence with CPAP treatment can be improved.

Citation:

Pliska BT, Almeida FR. Tooth movement associated with CPAP therapy. J Clin Sleep Med. 2018;14(4):701–702.


INTRODUCTION

Positive airway pressure therapy continues to be the first line of treatment for obstructive sleep apnea (OSA); however, the health effects of treatment may be limited if suboptimal acceptance and adherence rates are seen.1 Positive airway pressure therapy has several known side effects including air leakage, skin abrasions, mouth and nose dryness, dermatitis, pressure intolerance, and aerophagia.2 Dental changes with OSA treatment are often associated with oral appliances that function to reposition the mandible forward.3 Though less widely reported, dental and skeletal changes associated with continuous positive airway pressure (CPAP) are also known to occur.4 As it has been reported that some side effects lead to poor adherence or even termination of treatment,5 managing side effects has been recognized as a means to improve adherence. Here we report on the presentation, management, and means of preventing unwanted tooth movement associated with CPAP therapy.

REPORT OF CASE

A 64-year-old woman (body mass index 37.0 kg/m2) presented to an orthodontic practice for evaluation of unexplained tooth movement and spaces opening between her anterior teeth. These changes were of considerable concern for the patient who thought that she could no longer incise food using her anterior teeth. (Figure 1) A review of the patient's dental history was negative for periodontal disease, oral habits (thumb/ finger sucking, lip biting etc.), or other factors that could be responsible for the observed dental changes. Dental radiographs ruled out localized periodontal bone loss or diminished alveolar bone support for the anterior teeth. The patient's medical history was unremarkable except for recently diagnosed mild OSA (apnea-hypopnea index = 8.5 events/h), for which she had been using CPAP at a pressure of 10 cmH2O delivered by a nasal pillows interface for the past 18 months. Excellent adherence of nightly use averaging at least 7 hours was reported, as the patient found significant improvement in quality of life and daytime sleepiness associated with the refreshed sleep she achieved using CPAP. Follow-up questioning revealed that shifting of the teeth was first noticed in the months following the initiation of CPAP use. Dental casts of the patient taken for a crown restoration of a lower molar in the year prior to CPAP treatment confirmed the spacing was a recent phenomenon. The patient commonly felt tooth sensitivity in the mornings upon wakening, and reported that she forced her tongue forward against her teeth when the CPAP interface was in place.

Malocclusion and corrected occlusion.

(top) Initial presentation of malocclusion with spacing between the maxillary and mandibular anterior teeth resulting from protrusion of the patient's tongue during CPAP use. (bottom) Final corrected occlusion following 12 months of orthodontic treatment. The correction was maintained at the 9-month recall visit despite ongoing CPAP use with concurrent wear of an orthodontic retainer. CPAP = continuous positive airway pressure.

jcsm.14.4.701a.jpg

jcsm.14.4.701a.jpg
Figure 1

Malocclusion and corrected occlusion.

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The patient was encouraged to continue CPAP use despite the concerns with dental shifting and agreed to undergo limited orthodontic treatment with removable appliances to correct her malocclusion. Following 12 months of orthodontic treatment, the malocclusion was corrected and teeth returned to their pretreatment positions. (Figure 1) Subsequent to the orthodontic treatment the patient was provided an orthodontic retainer appliance (Figure 2) to maintain the position of her teeth, which has successfully prevented any further unwanted tooth movement associated with the ongoing CPAP therapy.

Simple plastic orthodontic retainer suitable for prevention of tooth movement.

The retainer is shown partially seated on a dental model to aid visualization.

jcsm.14.4.701b.jpg

jcsm.14.4.701b.jpg
Figure 2

Simple plastic orthodontic retainer suitable for prevention of tooth movement.

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DISCUSSION

Any sustained force or pressure on teeth has the potential to cause tooth movement. As such, it is reasonable that flaring of the anterior teeth would occur as a consequence of delivering positive pressure posterior to the tongue that functions to position it forward in the oral cavity and against the anterior teeth. In the case of this patient all other plausible explanations for the dental movement had been ruled out by multiple dental specialists. There are numerous case reports documenting the skeletal and dental changes associated with prolonged CPAP use in children,6,7 for whom continued growth makes changes readily apparent. The sole previous report of dental changes in adult CPAP patients demonstrated that after a minimum of 2 years of nasal CPAP use, there is clinically significant retrusion of the anterior maxilla and lingual or inward tipping of the maxillary anterior teeth.4 This is in contrast to the labial or outward tipping of the anterior teeth of both arches observed in the current presented case, a difference likely due to the different interfaces used between the two studies. Tsuda and colleagues4 specifically reported the dental changes of patients using a nasal mask, which can apply considerable pressure on the upper lip and underlying maxillary anterior teeth, resulting in the movements reported. The nasal pillows interface, however, does apply the same pressure to the upper lip, and in the current patient's case, caused her tongue to protrude forward against the anterior teeth, moving them labially.

It is likely that there is a high degree of variability in tooth movement with positive airway pressure, as there is a wide variation of individual response in how the tongue is positioned during use, and also the direct location of pressure applied by the interface. Additionally, though the current case involved a relatively moderate 10 cmH2O, whether these side effects occur only beyond a certain pressure threshold is unknown. However, physicians prescribing positive airway pressure therapy should be made aware of the potential of dental changes, particularly as this may negatively affect quality of chewing and more importantly adherence of otherwise effective management of OSA. Should a patient report any dental or bite changes, timely referral to an orthodontist may be effective at correcting movements or preventing them before they occur.

DISCLOSURE STATEMENT

Work for this study was performed at UBC Faculty of Dentistry. All authors have seen and approved this manuscript. The authors report no conflicts of interest.

REFERENCES

1 

Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg. 2016;45(1):43. [PubMed]

2 

Weiss P, Kryger M. Positive airway pressure therapy for obstructive sleep apnea. Otolaryngol Clin North Am. 2016;49(6):1331–1341. [PubMed]

3 

Pliska BT, Nam H, Chen H, Lowe AA, Almeida FR. Obstructive sleep apnea and mandibular advancement splints: occlusal effects and progression of changes associated with a decade of treatment. J Clin Sleep Med. 2014;10(12):1285–1291. [PubMed Central][PubMed]

4 

Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA. Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea. Chest. 2010;138(4):870–874. [PubMed]

5 

Ulander M, Johansson MS, Ewaldh AE, Svanborg E, Broström A. Side effects to continuous positive airway pressure treatment for obstructive sleep apnoea: changes over time and association to adherence. Sleep Breath. 2014;18(4):799–807. [PubMed]

6 

Li KK, Riley RW, Guilleminault C. An unreported risk in the use of home nasal continuous positive airway pressure and home nasal ventilation in children: mid-face hypoplasia. Chest. 2000;117(3):916–918. [PubMed]

7 

Fauroux B, Lavis JF, Nicot F, et al. Facial side effects during noninvasive positive pressure ventilation in children. Intensive Care Med. 2005;31(7):965–969. [PubMed]