by John H. Tucker, DMD, DICOI, DABDSM
Is today at the office just another day for you? Do root
canals, routine restorations, crown and bridge and hygiene
checks fill your day? Are you asking yourself what else you can
do to get busier or increase patient retention?
What if I told you that your dental practice has 440 patients
with a dental-related disorder that you could help treat, make
money and save lives?1
It is a well-known fact that Sleep Apnea Syndrome has been
on the rise in both men and women and is continuing to grow.
In an article published in Sleep magazine, research found "93
percent of women and 82 percent of men with moderate SAS
have not been clinically diagnosed."2
What about sleep deprivation? "Unrecognized sleep-disordered
breathing in the general population is linked to motor
vehicle accident occurrence, and may account for a significant
portion of motor vehicle accidents."3
Children are also affected by sleep disordered breathing,
with three to 12 percent of children being habitual snorers. This
directly affects IQ scores, attention span and memory indexes in
children.4 Children with obstructive sleep apnea (OSA) consume
226 percent more health-care services than children without
So, why bring dental sleep medicine into your practice now?
If these stats aren't enough to get your juices flowing then let me
give you my own personal opinion, dentist to dentist. Dental
sleep medicine is where implant dentistry was 30 years ago.
We must first begin with understanding a few things: the
terminology of sleep medicine, diagnosis, treatment options, our
limitations and, most importantly, that we are entering the
physicians' and sleep labs' world.
The main function of sleep is to allow for the individual to
recover and re-energize. Sleep promotes synaptic efficiency, protein
synthesis, neurogenesis, metabolic restoration and growth.
Not only does our immune system reset itself during sleep, our
brain allows for daytime learning to be encoded and the information
to be consolidated. Dreaming is important for psychological
well-being and the prevention of depression and altered
mood states. One of the more common terms you will hear
when learning about sleep disordered breathing is apnea. Apnea
is the cessation of oronasal airflow for at least 10 seconds.
Another common term is hypopnea, a 50 percent (or more) reduction of oronasal airflow of at least 10 seconds. The apneahypopnea
index (AHI) is the average number of apneas and
hypopneas per hour of sleep.
The severity criterion for OSA is divided into four areas:
snorers, mild OSA, moderate OSA and severe OSA. Each category
progressively shows an increased AHI value; snoring and
sleep apnea fall under the umbrella of sleep-disordered breathing.
Obstructive sleep apnea is characterized by repetitive episodes
of complete (apnea) or partial (hypopnea) upper airway obstruction
occurring during sleep, resulting in an increased respiratory
effort and insufficient ventilation with intermittent arterial blood
gas abnormalities such as hypoxemia or a decrease in the partial
pressure of oxygen in the blood and hypercapnia, an increase in
the partial pressure of carbon dioxide. These pathologic conditions
cause the brain to be aroused to resume normal breathing.
Sleep-disordered breathing has a plethora of factors contributing
to its development, including obesity, age, hormone
imbalance, anatomically small airway, craniofacial abnormalities,
genetic disorders and malocclusion. According to the NIH
News, stroke is the number two cause of death worldwide.
Men who have sleep apnea have a twofold increase for stroke,
with the increased risk being comparable to adding 10 years to
a man's age.6
Snoring and sleep apnea result in poor quality of sleep, daytime
sleepiness, cardiovascular disorders and neurocognitive
problems to name a few.
Snoring occurs when soft tissue falls against the back of the
throat and vibrates as air moves through it, creating a vibration.
An important aspect of snoring is that it is considered to be a sign
or onset of sleep-disordered breathing. In fact, any noise heard
during respiration while an individual is sleeping
is considered an indication of a problem.
Snoring is not usually a complaint of the
patient but is a complaint of the partner.
While many of us focus on the noise of our partner's snoring, there are significant pathophysiologic conditions
that might develop such as Metabolic X Syndrome, defined
as having at least three of the following: too much abdominal fat,
high triglycerides, low HDL (good cholesterol) and high blood
pressure. Loud snorers have a more than twofold increased risk
of developing hyperglycemia and were 92 percent more likely to
have low levels of HDL.7 With 45 million Americans snoring
every night,8 you can see how sleep-disordered breathing is
wildly under-diagnosed, let alone treated.
Let's turn our attention to the symptoms of sleep apnea.
These are simple questions that you can begin to ask your
patients right now. Do you suffer from any of the following:
excessive daytime sleepiness, chronic snoring, gasping or choking
episodes during sleep, morning headaches, fatigue-related
automobile or work accidents, depression or unexplained personality
or cognitive changes? Other symptoms include: obesity,
decreased sex drive and impotence, oversized neck circumference,
sleep-related bruxing (in children as well) and GERD.
A few of the risk factors for OSA include obesity, increasing
age, male gender, anatomic abnormalities of the upper airway,
family history, alcohol or sedative use and smoking. You can see
that there is some overlap with the risk factors.
What's next? Your patient will need to see a board certified
sleep physician for an overnight sleep study that may be done in
a sleep lab or hospital. It is important to note that it is the physician
who must make the diagnosis of OSA and not the dentist.
Think of yourself as the wide receiver on a football team and the
physician is the quarterback. The overnight sleep study or
polysomnogram (PSG) is interpreted by the physician, a diagnosis
is made and, depending on the results, treatment with CPAP
or OAT is determined.
Treating OSA non-surgically includes behavior modification
CPAP and/or OAT. CPAP or Continuous Airway Pressure delivers
room air under pressure through the nose via a nasal mask.
The pressure forces the upper airway open and prevents obstruction.
CPAP is considered to be the gold standard or most effective
treatment of OSA, however, non-compliance to CPAP therapy ranges from 29 to 83 percent. Surgical treatments available
include the Uvulopalatopharyngoplasty (UPPP), which
carries a 50 percent success rate and includes removal of the soft
palate including the uvula and excess pharyngeal tissue.
Maxillary/mandibular advancement (MMA) is another form of
surgery to reposition the jaw forward to increase the size of the
airway. Non-surgical management of OSA includes the use of
oral appliance therapy (OAT), with an FDA-approved medical
device, a good choice to resolve OSA and snoring and a good
alternative when CPAP or surgery fall short. What is our role
as a dentist? We can provide screenings for our patients and
referrals when necessary. We can provide and monitor oral appliance
therapy as part of the treatment with the physician, and
monitor and treat potential side effects of appliance therapy
and follow up.
You can start today by asking your patients these questions:
- Do you snore?
- Have you ever been diagnosed with sleep apnea?
- Have you ever had an overnight sleep study?
- Do you or have you used a CPAP?
- Do you wake up in the morning with a headache?
- Have you ever been told you gasp for air or suddenly stop
breathing while sleeping?
You may also introduce sleep medicine into your practice by
giving your patients an Epworth Sleepiness Questionnaire, the
standard screening tool used by physicians to determine the
need for a sleep study. Medical insurance companies also use the
Epworth as part of the documentation needed for reimbursement
of CPAP or oral appliances.
We can evaluate:
- Neck size, making note of men with 17-inch or greater
size neck and women with greater than 15.5-inch neck
- Size and scalloping of the tongue
- Length of the palate
- Size of the uvula
- Crowding of the oropharyngeal area
Consider OSA to be a medical condition with a dental solution
and a physician leading the treatment. Add years to your
- 1. Chest 2006; 130, 780-786.
- Sleep, 20(9) 705-706 c. 1997
- Young Sleep 20(8) 608-13, 1997.
- Kennedy et al., 2004
- Sinha & Guilleminault, 2010.
- NIH News, April 08, 2010
- Troxel WM, Buysse DJ, Matthews KA, Kip KE, Strollo PJ, Hall M, Drumheller O, Reis SE. Sleep. 2010
- S. Scott, K. Ah-See, H. Richardson. Clinical Otolaryngology & Allied Sciences. 2003 Feb; 28 (1): 18-21.
Dr. John H. Tucker has maintained a private practice in Erie, Pennsylvania since 1982. He is a graduate of the University of Pittsburgh School of
Dental Medicine. He has completed the Boston Seminars in Implant Dentistry with Dr. Paul Schnitman, the University Of Buffalo Esthetic
Dentistry Program, and all levels of the Dawson Center for Advanced Dental Study, and the University Of Buffalo Patient Mastery Program. In
2005 he was awarded a Certificate of Proficiency in Esthetic Dentistry from the University of Buffalo.