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The Sleeping Giant in Your Practice by Dr. John H. Tucker

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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 OSA.5

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 circumference
  • Size and scalloping of the tongue
  • Length of the palate
  • Size of the uvula
  • Tonsils
  • 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 patients' lives.

References
  1. 1. Chest 2006; 130, 780-786.
  2. Sleep, 20(9) 705-706 c. 1997
  3. Young Sleep 20(8) 608-13, 1997.
  4. Kennedy et al., 2004
  5. Sinha & Guilleminault, 2010.
  6. NIH News, April 08, 2010
  7. Troxel WM, Buysse DJ, Matthews KA, Kip KE, Strollo PJ, Hall M, Drumheller O, Reis SE. Sleep. 2010 Dec; 33(12):1633-40.
  8. S. Scott, K. Ah-See, H. Richardson. Clinical Otolaryngology & Allied Sciences. 2003 Feb; 28 (1): 18-21.


Author's Bio
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.
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