ABDSM FINAL EXAM TEST 2025 LATEST UPDATE

In the pathophysiology of sleep apnea, airway patency and stability is promoted by which factor? A. Increased lung volume B. Shorter mandible C. Increased parapharyngeal fat deposition D. Negative inspiratory pressure E. Reduced pharyngeal muscle dilator activity - A. Increased lung volume Oral appliance therapy commonly provides successful sole therapy for which of the following sleep-related breathing disorders? A. Primary central sleep apnea B. Cheyne-Stoke periodic breathing C. Obesity hypoventilation D. Overlap syndrome (OSA and COPD) E. None of the above - E. None of the above Which of the following is true about OSA and HTN? A. Ambulatory BP is increased in OSA patients primarily due to increased salt intake associated with elevated ghrelin levels B. Ambulatory BP normally increases in the early AM before awakening - this increase is blunted in OSA C. Untreated OSA is associated with a similar risk of HTN at all severity levels D. The risk of HTN in untreated OSA is due to intermittent hypoxia, sympathetic overactivation, inflammation, and other complex factors - D. The risk of HTN in untreated OSA is due to intermittent hypoxia, sympathetic overactivation, inflammation, and other complex factors Across a general population, what is the most common sleep disorder? A. RLS B. Narcolepsy C. Delayed sleep phase syndrome D. Insomnia E. Obstructive sleep apnea - D. Insomnia Measurement has shown that patients with sleep apnea have smaller upper airways than those without sleep apnea but manage to keep an open airway during wakefulness by: A. Mouth Breathing B. Increased muscle tone on inspiration C. Increased blood flow to the soft tissue D. Frequent bruxing - B. Increased muscle tone on inspiration Key features of sleep apnea as recorded during an in-lab sleep study include marked reduction or absence of air flow, arousals from sleep, slowing of heart rate and: A. Choking or gasping for air B. Oxygen desaturation C. Flattening of the nasal pressure signal D. Flailing of the arms and legs E. Sawtooth waves in the EEG - B. Oxygen Desaturation Who publishes the CPT codebook? A. The Centers for Medicare and Medicaid Services B. The American Medical Association C. The Office of the Inspector General D. The Durable Medical Equipment Service E. The American Academy of Sleep Medicine - B. The American Medical Association A 48 year old man is treated with OAT for his moderate OSA. On repeat sleep testing, his apnea-hypopnea index (AHI) has decreased to 3 events per hour, and he reports resolution of snoring and daytime sleepiness. What is the most reasonable dental-medical sleep medicine follow up regimen for this patient? A. As needed B. Every 6 months for the first year, then annually C. Monthly for the first 6 months, then every 6 months D. Every other year - B. Every 6 months for the first year, then annually Which of the following would exclude oral appliance therapy as a first treatment trial for OSA? A. Xerostomia B. Edentulism C. Micrognathia D. Steep mandibular plane angle - B. Edentulism Reviewing your patient's diagnostic polysomnogram, you note more than a 50% epoch consists of alpha waves. According to the current PSG scoring guidelines, the patient is in which stage of sleep? A. Stage I NREM B. Stage II NREM C. Stage III NREM D. Stage REM - A. Stage I NREM A patient presents for an evaluation to determine their candidacy for an oral appliance to treat their mild OSA. During your examination, you note the presence of TMD. This might include the following: A. Pain in the TMJ B. Pain in the muscles of mastication C. Anomalies in mandibular movement D. All of the above - D. All of the above The qualified dentist designation (QDD) came about in response to the 2015 practice guidelines paper recommending that physicians refer patients to dentists "qualified" to treat sleep related breathing disorders. This was based upon recognition of which of the following? A. Older dentists have more experience than younger dentists B. All dentists have the skills they need to deliver knowledgeable care C. Oral appliance efficacy data collected in studies is obtained by dentist with extensive clinical experience D. Training in dental schools on oral appliance therapy has become common place - C. Oral appliance efficacy data collected in studies is obtained by dentist with extensive clinical experience The 2015 Practice Guidelines created through cooperative effort of the AASM and AADSM suggest a physician should seek collaboration with a qualified dentist, described as someone who has at least: A. Board certification B. Facility accreditation C. Completion of a 1 yr residency in dental sleep medicine D. Additional training or experience in dental sleep medicine - D. Additional training or experience in dental sleep medicine An understanding of loop gain is important to the clinical practice of dental sleep medicine because: A. It excludes the possibility of cheyne stokes breathing in patients with severe OSA B. It is the basis of the Mallampati classification system C. It defines the number of sequential obstructive apneas in an epoch D. It contributes to the multifactorial nature of sleep related breathing disorders - D. It contributes to the multifactorial nature of sleep related breathing disorders With regards to biomechanical properties of the upper airway, which statement is true? A. Sleep apnea patients paralyzed during general anesthesia (neural drive removed) demonstrated airway compliance similar to healthy subjects B. Sleep apnea patients had more negative closing pressures C. Sleep apnea patients demonstrate a more positive Pcrit D. There is no correlation between collapsibility when awake and collapsibility when asleep - C. Sleep apnea patients demonstrate a more positive Pcrit Tagged MRI recently showed 3 patterns of tissue formation during mandibular advancement. Which of these was NOT observed? A. The whole tongue moved forward "en bloc" B. Only the superior posterior portion of the tongue moved forward C. The posterior tongue did not move, but the whole tongue elongated D. Only the inferior posterior portion of the tongue moved forward - B. Only the superior posterior portion of the tongue moved forward In Van Heasendonck's 2015 systematic review of oral appliance health benefits, mean disease alleviation was calculated using the following: A. An embedded microsensor B. A highly compliant patient population C. Patient's diaries of hours of nightly device use D. Patient's attestations to hours of nightly device use - A. An embedded microsensor Caffeine promotes wakefulness by suppressing or blocking: A. Thyroid stimulating hormone B. Growth hormone C. Orexin D. Adenosine - D. Adenosine A study design where one or more population samples are followed prospectively to determine which participant's exposure characteristics (risk factors) are associated with a disease or outcome is called a: A. Randomized control trial B. Non-randomized control trial C. Cohort study D. Case control study - C. Cohort study In an experiment where participants are randomly assigned, one group receives the drug or procedure, a placebo group's treatment is disguised to resemble the drug or procedure being investigated and a control group receives nothing. Members of each group are prevented from knowing whether they are receiving active therapy. This would be called a: A. Randomized control trial B. Cohort study C. Randomized case report D. Blinded triple trial - A. Randomized control trial The masseter muscle originates at: A. The temporal fossa B. The zygomatic arch C. The mylohyoid ridge D. The coronoid process - B. The zygomatic arch In Sheats et. al., a morning occlusal guide is a common side effect management modality. Which of the following is CORRECT? A. A MOG encompasses many custom made appliances and prefabricated devices used in an effort to reposition the mandible into its habitual pre-treatment position B. A MOG has a very specific design as established by the AADSM consensus committee on side effects C. A morning occlusal guide was shown to stretch the lateral pterygoid muscle to full functional length with EMG studies D. Use of an MOG assures the patient that there will be no bite changes as a result of use of an oral appliance - A. A MOG encompasses many custom made appliances and pre-fabricated devices used in an effort to reposition the mandible into its habitual pre-treatment position All of the following exacerbate sleep disordered breathing, EXCEPT: A. Use of stimulants within 1 hr of bedtime B. Consumption of a heavy meal within 1 hr of bedtime C. Use of melatonin within 1 hr of sleep onset D. Use of alcohol, especially as a means to induce sleep - C. Use of melatonin within 1 hr of sleep onset A patient presents to consult with you regarding oral appliance therapy for their moderate OSA. They report intermittent "jaw pain" for the past 6 weeks. You should explain that: A. It is best to postpone treatment until the pain has resolved B. An oral appliance is contraindicated for a patient that has active TMD C. A comprehensive oral-facial evaluation is necessary to ID the source of their jaw pain before considering or proceeding with oral appliance therapy D. An oral appliance will improve their jaw pain if the source of the pain is muscular, and not originating from the TMJ - C. A comprehensive oral-facial evaluation is necessary to ID the source of their jaw pain before considering or proceeding with oral appliance therapy The most recent research points to the primary etiology of sleep bruxism as: A. Nicotine, ethanol, recreational drug or caffeine use B. Peripheral triggers such as occlusal discrepancies C. Central factors such as stress and psychosocial influences D. The result of a combination of environmental, biological, and psychosocial influences - D. The result of a combination of environmental, biological, and psycho-social influences According to Caples, et al, risk of fatal and non-fatal cardiovascular events is significantly increased in patients with: A. Mild OSA B. Severe OSA C. Severe OSA on CPAP therapy D. Both A and B - B. Severe OSA In sleep, heart rate... - Slows 10-15 BPM In sleep, breathing... - slows In sleep, muscles - relax In sleep, BP - Decreases (morning dip) In sleep, body temperature... - Decreases, then begins to rise just before morning wakeup time Which neurons are sleep promoting? - - Ventrolateral Preoptic System (VLPO) - Median Preoptic Nuclei (MNPO) Loss of which neurons promotes profound insomnia and sleep fragmentation? - VLPO What does the flip flop switch refer to? - Mutual inhibition of sleep and wake promoting neurons triggered by changes in drive for sleep or circadian altering signal When do the deepest stages of sleep occur? - 20 minutes after sleep onset What is referred to as the circadian pacemaker? - SCN (Suprachiasmatic nuclei of anterior hypothalamus) What does the SCN promote? - Wakefulness, and maintains sleep after sleep drive dissipates in the 2nd half of the jight Where is melatonin released? - Pineal gland Regulated by SCN Is melatonin necessary for sleep? - No, but helps synchronize circadian rhythms What causes sleep drive to buildup throughout the day? - Buildup of adenosine Induces sleep by inhibiting wake promoting neurons What neurotransmitter does caffeine inhibit? - Adenosine Promotes wakefulness What are some characteristics of REM? - - Increased brain wave activity - Eyes move back and forth rapidly - Atonic muscles - Dreaming - High cholinergic, low adrenergic state When is REM more prominent? - Second half of the night - and episodes lengthen throughout the night What % REM do premature infants have? - 80% What % REM do full term neonates have? - 50% What % REM do adults 20-69 have? - 25% How much sleep does N1 encompass? - 5-10% Very light sleep How much sleep does N2/N3 encompass? - 65-70% What phase of sleep are sleep spindles present in? - Mostly N2 Very small amount present in N3 Where do sleep spindles originate? - Thalamus Where do sleep spindles propogate? - Cortex What are sleep spindles associated with? - Offline memory processes **Get increased spindle activity after learning What waves are associated with N1 sleep? - Vertex sharp waves - alpha waves What sleep study architecture is associated with N2 sleep? - - K complexes - Sleep spindles When do REM stages start? - 80-100 minutes after onset of sleep How long are the cycles between REM and NREM? - 90 minutes What are the main purposes of sleep? - - Enhance memory consolidation - Promote alertness - Hormone release (ADH, GH, Oxytocin, Prolactin) - Clear metabolites from brain How much does brain energy metabolism decrease by during sleep? - 25% What hormones are released during sleep? - - GH - ADH - Oxytocin - Prolactin What does the glymphatic system do? - Flushes out toxins, proteins, metabolic waste from the brain How is the sleep cycle in a newborn different? - - Enter REM before NREM - Shorter sleep cycles (50 min as opposed to 90 min) - 50% REM (declines over first 2 yrs to 20-25%) - No Slow Wave Sleep (N3) What phase of sleep does slow wave sleep occur in? - N3 How does slow wave sleep change over time? - - Not present at birth - Emerges in first 2 years - Decreases during adolescence by 40% in preteen years How is N3 sleep different between men and women? - Women have a higher % of N3 sleep than men, and it decreases slower throughout life Where are central chemoreceptors located? - Ventral Medulla on brain What do central chemoreceptors detect? - - CO2 - H+ Where are peripheral chemoreceptors located? - Carotid Body What are peripheral chemoreceptors sensitive to? - - HYPOXIA - Also detect changes in CO2, pH, temperature What mainly controls alveolar ventilation? - Arterial CO2 Have a linear relationship of minute ventilation as CO2 increases How does O2 relate to ventilation drive? - Minimum O2 ventilation drive until PO2 <60, then get enhanced ventilation How does CO2 relate to ventilation drive? - Linear relationship - minute ventilation increases as CO2 increases What is the definition of apnea? - Cessation of airflow for 10 seconds or longer What is the definition of hypopnea? - Decrease in airflow lasting for 10+ seconds 30% reduction of airflow AND At least a 3% oxygen desaturation OR an arousal (CMS says 4%) Shallow breathing Decreased minute ventilation Why do humans have sleep apnea and others do not? - Longer, more collapsible airway. No overlap of epiglottis and soft palate Allows advanced speech but unprotected airway during sleep What is the measure of airway patency? - Pcrit Determined by sum of structural and neuromuscular determinants of airway collapsibility What does more negative Pcrit mean? - Airway is open Pcrit<-10 in normal subjects What are the 2 fundamental sleep induced changes in OSA? - - Changes in passive mechanics of upper airway - Critical reliance on chemosensitivity for control of respiratory motor output and its stability Where does the obstruction most often occur in OSA? - Soft palate (81%) Where else can the obstruction occur in OSA? - - Tongue base (46.6%) - Hypopharyngeal collapse (38.7%) - Multilevel collapse - most common is palate and tongue base How many adults have mild OSA? - 1/5 How many adults have moderate-severe OSA? - 1/15 What are some risk factors for OSA? - - Obesity - Male - Diabetes - HTN - Postmenopausal - Large neck >16 inches - Atrial fibrillation - African american, asian, hispanic - Frequent nocturia - Upper airway anatomic obstruction What is a normal score on the ESS? - <10 What are some diurnal symptoms of OSA? - - Daytime sleepiness - Memory and concentration dysfunction - GERD - Irritability, depression - Traffic accidents - Waking with a dry mouth, irritated throat What are some nocturnal symptoms of OSA? - - Heavy, persistent snoring - Apnea with limb movement - Nocturia - Nocturnal sweating - Sudden awakening with noisy breathing - Accidents related to sleepiness - Insomnia What does AHI consist of? - Apneas + Hypopneas What is the difference in AHI and RDI? - RERAs are included for RDI CMS views AHI = RDI because they don't recognize RERA's What is considered mild OSA? - 5-15 RDI per hour CMS will cover OSA therapy if comorbidity like: - HTN - Stroke - Sleepiness - Ischemic heart disease - Insomnia - Mood disorders What is considered moderate OSA? - 15-30 RDI per hr What is considered severe OSA? - 30+ RDI per hr What is ODI? - Oxygen desaturation index # of 3% desaturations per hr What does a CPAP do? - - Splints airway open - + pressure decreases fluid leakage into alveoli - + pressure decreases work of breathing and O2 requirements - Improves cardiac function and output by decreasing preload and afterload - Increases lung volume Does CPAP prevent CV disease in patients with CVD + OSA? - No - not compared to usual care alone What is the compliance rate for CPAP? - 30-70% Is nasal patency a major contributor to OSA? - NO - using nasal dilators doesn't significantly improve nasal flow or apnea index What are the 3 patterns of tissue deformation during mandibular advancement? - - Whole tongue moves forward en bloc - Whole tongue elongates - Inferior tongue moves forward **POSTERIOR TONGUE DOESN'T MOVE What are the cardiovascular benefits of oral appliance therapy? - - Reduced BP (34-75%) - Endotheilal and left ventricular function improves Does bariatric surgery/weight loss cure OSA? - No - most patients will still have moderate residual OSA - still needs treatment Does reduce AHI though How are apneas scored? What are the requirements? - Decreased flow signal >90% for >10 seconds BOTH must be met What is the difference between obstructive and central apnea? - Obstructive has continued effort, central has no effort Mixed = absence of effort initially followed by resumption of effort What are the requirements for a hypopnea? - - Decreased flow >30% of baseline for >10 seconds - A 3% oxygen desaturation from baseline OR an arousal **CMS requires 4% When is a hypopnea considered obstructive? - If any of the following occur: - Snoring - Inspiratory flattening - Thoracoabdominal paradox What is a RERA? - Breathes >10 seconds by increasing rate or flattening, leading to an arousal when it doesn't meet criteria for apnea or hypopnea When MUST you do a PSG over HST? - - Cardiorespiratory disease - Neuromuscular weakness - Hypoventilation - Opiate use - Hx of stroke - Severe insomnia What are the 3 primary signals tested with hST? - - Airflow - Respiratory effort - Oximetry Do HST's over or underestimate OSA severity? - Overestimate What do HST's not measure? - Total sleep time, RERA's How is sleep monitored with HST? - SCOPER - Sleep - Cardiac measure - Oximetry - Position - Effort - Respiration How does OSA treat SDB? - - Maintains mandible closed - Increases anterior and lateral dimensions of oropharynx - Increases anterior and lateral dimensions of velopharynx - Increases base of tongue muscle tone What are some observed changes with OAT? - - Increased lower face height - Lateral displacement of parapharyngeal fat pads - Anterior positioning of base of tongue - Increase in total airway volume What are some craniofacial characteristics that lead to increased risk of OSA? - - Reduced mandibular body length - Inferiorly positioned hyoid bone - Retroposition of maxilla - Airway length What % of patients use CPAP >4 hrs per night after 6 months? - 50% What reduces AHI more, CPAP or OAT? - CPAP Does OAT reduce BP? - Data is limited, but in some patient populations, it is as effective as CPAP at reducing BP What factors are equal between OAT and CPAP? - - Quality of life - Effect on BP, endothelial function - Cognitive performance - Daytime sleepiness - Reduction in arousal index - Increased oxygen saturation What are the main side effects of CPAP? - Irritated nose and mouth When might a tongue retaining device be helpful? - - Ortho - Edentulous - Pts with TMD who can't tolerate an MAD What are the requirements of an oral appliance? - - Allows advancements of 1mm or less - Protrusive range of 5+mm - Can be placed by patient or caregiver - Maintains stable relationship to teeth, implants, or edentulous ridge - Maintains structural integrity for a minimum of 3 years How does protrusion alter the architecture of the airway? - - Displaces the suprahyoid and genioglossus muscle - Advances and moves the mandible downward - increases tension on palatoglossal and palatopharyngeal muscles of the soft palate to maintain space in velopharynx - Hyoid and mandible are held forward preventing backward rotation of mandible and posterior displacement of tongue into airway - Lateral walls move laterally along the pterygomandibular raphe What are the indications for MADs? - - Minimum of 10 sound teeth per jaw - <20% tooth height destroyed by bruxism - Ability to protrude the jaw 5-8 mm min - Minimum maximum opening of 25-40 mm What are some contraindications for MAD's? - - Protrusion of mandible <5mm - Active severe TMD - Painful opening or chewing - Painful TMJ noise/locking - Insufficient tooth support for the device - PDD or tooth mobility What is the single most important modifiable cause of sleep disordered breathing? - Weight gain What stages of sleep is sleep bruxim most common in? - NREM 1 and 2 Where in the TMJ does rotation occur? - Lower compartment - first 20 mm of opening Translation occurs in the upper compartment Describe the articular disc - - Extension of fibrous capsule - No innervation or blood supply - Biconcave (like a bowtie) Where does the anterior portion of the articular disc connect? - Superior head of lateral pterygoid Where does the posterior portion of the articular disc connect? - Turns into highly innervated retrodiscal tissue How is the articular disc held to the condyle? - Medial and lateral collateral ligaments What nerve innervates the TMJ? - Mandibular division of the trigeminal - Auriculotemporal - Deep temporal - Masseteric What's the origin and insertion of the masseter? - Origin: Zygomatic arch Insertion: Angle, Ramus What nerve innervates the masseter? - Masseteric nerve (V3) What is the action of the masseter? - Elevates mandible What's the origin and insertion of the temporalis? - Origin: Temporal fossa Insertion: Coronoid process of mandible What nerve innervates the temporalis? - Temporalis nerve What are the actions of the temporalis? - Elevates and retrudes the mandible What's does the inferior belly of the lateral pterygoid do? - Depresses the mandible What does the superior portion of the lateral pterygoid do? - Maintains articular disc position during rest and movement What's the origin and insertion of the medial pterygoid? - Origin: Medial surface of lateral pterygoid plate Insertion: Medial surface of mandible What does the medial pterygoid do? - Protrudes and elevates the mandible What are the signs/symptoms of synovitis? - - History of trauma - Continuous TMJ pain - Tender to palpation - NORMAL ROM - Acute malocclusion on injured side **PAIN WITH CLENCHING, BUT NOT WHEN CLENCHING ON TONGUE DEPRESSOR What's the treatment for synovitis? - - Anti-inflammatories - Physical therapy - Aqualizer or soft splint - Hard splint if necessary - Iontophoresis - Phonophoresis What are the characteristics of temporal tendonitis? - - Pain at temporalis insertion - Possible joint, ear, cheekbone, molar pain - Could feel like a migraine and cause limited opening What's the treatment for temporal tendonitis? - - Injection insertion - Physical therapy What are the characteristics of a non-reducing disc displacement? - - Maximum opening 26 mm - Deflection TO affected side - No clicking - History of locking - History of reducing disc displacement How do you diagnose a non-reducing disc displacement? - MRI with closed and wide open views What is the difference between deviation and deflection? - Deviation: Jaw goes to the side as you open then recenters at maximum opening Deflection: Jaw opens and stays off to one side at maximum opening What is normally the reason for pain in the TMJ after OAT? - Too much/little protrusion What is normally the reason for pain in the masseter after OAT? - Usually due to too much vertical, lack of posterior support, or uneven posterior support How does a case control study work? - Those with disease get matched with those without disease Look back in time for an exposure What is a cohort study? - No disease present to start Each group exposed to different factors - determine which group has more disease over time What does the P value measure? - Statistical significance - NOT clinical significance So shows there is a difference in effect between two things, but not the number needed to treat or the magnitude of the effect What P value shows something is due to chance? - P > 5% Which is more effective at managing mild to moderate OSA with a MAD, 50% or 75% protrusion? - Either - they are equal For severe OSA, 75% protrusion is slightly more effective