Amandeep Bains, MD

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device often is most beneficial for supine-dependent sleep apnea patients and those with loud snoring, without sleep apnea.⁴ Response is best in young adults and in patients who have a low body mass index, are free of sedatives, and have appropriate cephalometrics of the oral, dental, or pha­ryngeal anatomy. Improved sleep architec­ture, continuous sleep with less snoring, and increased daytime alertness are observed in patients who respond to an AMP device.

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device often is most beneficial for supine-dependent sleep apnea patients and those with loud snoring, without sleep apnea.⁴ Response is best in young adults and in patients who have a low body mass index, are free of sedatives, and have appropriate cephalometrics of the oral, dental, or pha­ryngeal anatomy. Improved sleep architec­ture, continuous sleep with less snoring, and increased daytime alertness are observed in patients who respond to an AMP device.

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Snoring, snorting, gasping, and obstruc­tive sleep apnea are caused by col­lapse of the pharyngeal airway during sleep.¹ Pathophysiology includes a combi­nation of anatomical and physiological vari­ables.¹ Common anatomical predisposing conditions include abnormalities of pharyn­geal, lingual, and dental arches; physiologi­cal concerns are advancing age, male sex, obesity, use of sedatives, body positioning, and reduced muscle tone during rapid eye movement sleep. Coexistence of anatomic and physiological elements can produce significant narrowing of the upper airway.

Comorbidities include vascular, meta­bolic, and psychiatric conditions. As many as one-third of people with symptoms of sleep apnea report depressed mood; approx­imately 10% of these patients meet criteria for moderate or severe depression.²

In short, sleep-disordered breathing has a globally negative effect on mental health.

When should you consider obtaining a sleep apnea study?
Refer patients for a sleep study when snor­ing, snorting, gasping, or pauses in breathing occur during sleep, or in the case of daytime sleepiness, fatigue, or unrefreshing sleep that cannot be explained by another medical or psychiatric illness.² A sleep specialist can determine the most appropriate intervention for sleep-disordered breathing.

An apneic event is characterized by complete cessation of airflow; hypopnea is a partially compromised airway. In either event, at least a 3% decrease in oxygen saturation occurs for at least 10 seconds.³ A diagnosis of obstructive sleep apnea or hypopnea is required when polysomnography reveals either of:
   • ≥5 episodes of apnea or hypopnea, or both, per hour of sleep, with symptoms of a rhythmic breathing disturbance or daytime sleepiness or fatigue
   • ≥15 episodes of apnea or hypopnea, or both, per hour of sleep, regardless of accom­panying symptoms.²

What are the treatment options? 
   • Continuous positive airway pressure (CPAP) machines.
   • Surgical procedures include adeno-tonsillectomy in children and surgical maxilla-mandibular advancement or pala­tal implants for adults.
   • A novel implantable electrical stimu­lation device stimulates the hypoglossal nerve, which activates the genioglossus muscle, thus moving the tongue forward to open the airway.
   • An anterior mandibular positioning (AMP) device increases the diameter of the retroglossal space by preventing posterior movement of the mandible and tongue, thereby limiting encroachment on the air­way diameter and reducing the potential for collapse.^1-4

When should you recommend an AMP device?
Consider recommending an AMP device to treat sleep-disordered breathing when (1) lifestyle changes, such as sleep hygiene, weight loss, and stopping sedatives, do not work and (2) a CPAP machine or a surgical procedure is contraindicated or has been ineffective.¹ An AMP device can minimize snoring and relieve airway obstruction, especially in patients with supine position-related apnea.⁴ To keep the airway open in non-supine position-related cases, an AMP device might be indicated in addition to CPAP delivered nasally.¹

This plastic oral appliance is either a 1- or 2-piece design, and looks and is sized simi­larly to an athletic mouth-protection guard or an oral anti-bruxism tooth-protection appliance. It is affixed to the mandible and maxillary arches by clasps (Figure).

An AMP device often is most beneficial for supine-dependent sleep apnea patients and those with loud snoring, without sleep apnea.⁴ Response is best in young adults and in patients who have a low body mass index, are free of sedatives, and have appropriate cephalometrics of the oral, dental, or pha­ryngeal anatomy. Improved sleep architec­ture, continuous sleep with less snoring, and increased daytime alertness are observed in patients who respond to an AMP device.

An AMP device is contraindicated when the device cannot be affixed to the dental arches and in some patients with an anatom­ical or pain-related temporomandibular joint disorder.⁵ The device is easy to use, nonin­vasive, readily accessible, and less expensive than alternatives.³

How can you help maintain treatment adherence?
AMP devices can induce adverse effects, including dental pain or discomfort through orthodontic alterations; patient reports and follow-up can yield detection and device adjustments can alleviate such problems. Adherence generally is good, with complaints usually limited to minor tooth discomfort, occlusive changes, and increased or decreased salivation.⁵ In our clinical experience, many patients find these devices comfortable and easy to use, but might complain of feeling awkward when wearing them.

Changes in occlusion can occur during long-term treatment with an AMP device. Proper fitting is essential to facilitate a more open airway and the ability to speak and drink fluids, and to maintain safety, even if vomiting occurs while the device is in place.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.