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CE: Introduction to OSA and Dental Sleep Medicine-Part 1 by Drs. Stephanie Dennison, Larry Cohen and William Jacobson

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CE: Introduction to OSA and Dental Sleep Medicine-Part 1 

Part 1: A 3-step screening guide for general dentists

by Drs. Stephanie Dennison, Larry Cohen and William Jacobson

Short description
This course outlines the steps for a general dentist to effectively screen and refer patients for obstructive sleep apnea (OSA). The risk factors of OSA, how to take a sleep history, and when and how to refer a patient at risk for OSA will be discussed.


Abstract
This course will provide an effective protocol for general practitioners to screen patients for OSA and refer those at risk. The screening protocol will consist of three steps: medical history intake, clinical examination and sleep history. A discussion on when and how to refer at-risk patients for OSA will also be included.
  • Screening Step 1: During the medical history intake, it is important to consider the systemic conditions associated with OSA. Many common cardiovascular, metabolic and neurologic diseases are comorbid with OSA. Additional systemic factors, such as male sex, advanced age, drug and alcohol use, and a family history of OSA, should also be taken into account.
  • Screening Step 2: During the extraoral and intraoral examination, it is essential to recognize hard and soft tissue anatomy that predisposes a patient to airway collapse. Examples include retrognathia, a narrow and high-arched palate, mandibular tori, enlarged palatine tonsils, and macroglossia. It is also crucial to be aware of non-carious tooth structure loss associated with OSA, such as attrition and acid erosion.
  • Screening step 3: If, after the routine medical history intake and clinical examination, you have identified risk factors for OSA, it is important to consult with your patient about their sleep. A brief sleep history should be obtained. Wake and sleep symptoms of OSA should be evaluated. Validated OSA questionnaires, such as the STOP-BANG or Epworth Sleepiness Scale, can also be easily administered.
    • If a patient displays risk factors for OSA and their sleep history raises concerns, they should be counseled and referred to their primary care provider (PCP) for further evaluation.

 Learning objectives
After completing this course, readers should be able to:
  1. Identify systemic conditions that are comorbid with OSA.
  2. Recognize both soft and hard tissue anatomy that predisposes a patient to airway collapse or indicates a risk of OSA.
  3. Conduct a sleep history to assess a patient’s risk of OSA further.
  4. Effectively refer a patient at risk for OSA to their PCP.
Introduction
Obstructive sleep apnea is a sleeprelated breathing disorder marked by recurrent episodes of partial or complete upper airway collapse, despite ongoing ventilatory effort. These episodes lead to sleep fragmentation and numerous adverse physiological effects. If left untreated, OSA can lead to poor systemic health and well-being, increased all-cause mortality, decreased productivity and a higher risk of automobile accidents.1 In 2015, it was estimated that unmanaged OSA costs the United States $150 billion in direct and indirect costs.2 For these reasons, OSA is widely acknowledged as a public health crisis. Nevertheless, it is projected that 80% of individuals with OSA remain undiagnosed and untreated.3

Dental professionals are uniquely positioned to identify and refer patients at risk for OSA because of their regular contact with patients and their anatomical knowledge of the oral and maxillofacial regions. In fact, the American Dental Association (ADA), American Academy of Dental Sleep Medicine (AADSM), and American Academy of Sleep Medicine have published policy statements and clinical practice guidelines outlining the role of dentistry in the prevention and management of sleep-related breathing disorders.4, 5, 6 Most risk factors for OSA can and should be identified during routine dental visits. Referral to a patient’s primary care provider should occur when a patient at risk for OSA is identified. By doing so, dental practitioners can play an integral role in the diagnosis and management of OSA patients, helping alleviate this public health crisis.


SCREENING STEP 1
Medical history intake
Reviewing a patient’s medical history is a routine part of every dental visit. Being aware of systemic conditions that are comorbid with OSA is essential for identifying at-risk patients. Here is a list of comorbid conditions associated with OSA. While most dental practitioners possess a basic understanding of these conditions and their effects on dental treatment and overall health, understanding their connection to OSA is crucial when screening for OSA.

Comorbid systemic conditions:
  • Chronic heart or lung disease
  • Congestive heart failure
  • Atrial fibrillation
  • Abnormal heart rhythm
  • Hypertension and treatmentresistant hypertension
  • Pulmonary hypertension and treatment-resistant pulmonary hypertension
  • Stroke
  • Overweight/obese (BMI > 30 kg/m²)
  • Cryptogenic epilepsy
  • Type II diabetes
  • Hypothyroidism
  • Mood disorders
  • Pain disorders
  • Family history of snoring or OSA
  • Nasal congestion
  • Other: tobacco use, alcohol use, male sex, increased age (middle-aged or older)

SCREENING STEP 2
Extra/intraoral examination
Dentists can pinpoint anatomical risk factors for OSA during a routine clinical exam, alongside identifying systemic conditions that are comorbid with OSA, by reviewing the patient’s medical history. These anatomical findings predominantly reflect variations in soft and hard tissues that predispose a patient to upper airway collapse. They can be broadly summarized as factors that either increase soft tissue volume in or around the upper airway, or restrict the size of the bony compartment enclosing the upper airway. Additionally, signs of non-carious tooth structure loss, such as attrition and acid erosion from sleep bruxism and acid reflux, respectively, can also suggest a risk of OSA.

Soft tissue risk factors:
  • Obese neck circumference (male > 17”, female > 16”)
  • Macroglossia (tongue scalloping)
  • Ankyloglossia
  • Limited visibility of oropharyngeal structures
  • Long, broad or erythematous uvula
  • Enlarged palatine tonsils
Hard tissue risk factors:
  • Retrognathia
  • Micrognathia
  • Steep mandibular plane angle
  • Large mandibular tori
  • Maxillary constriction with a high vaulted palate
  • Craniofacial syndromes (e.g., Down Syndrome)
  • Attrition and acid erosion

SCREENING STEP 3
Sleep history
If risk factors for OSA are identified during the medical history intake and clinical exam, the general practitioner should then inquire about the patient’s sleep. This can be achieved by conducting a basic sleep history that involves asking the patient about potential wake and sleep symptoms of OSA. Information regarding the patient’s sleep symptoms can often be enhanced by questioning the patient’s bed partner. Simple, validated OSA screening tools, such as the STOP-BANG questionnaire, Epworth Sleepiness Scale or Berlin questionnaire, can also be employed. The suggested symptoms to evaluate, along with the STOP-BANG questionnaire, are outlined below.


OSA symptoms
Wake symptoms:
  • Excessive daytime sleepiness
  • Morning dry mouth, sore throat, headaches, temporomandibular disorder
  • Memory/focus problems
  • Mood changes
  • Car crashes
  • Absenteeism, declining performance at work
Sleep symptoms:
  • Insomnia
  • Loud snoring
  • Witnessed apneas
  • Choking or gasping arousals
  • Restless sleep (multiple nocturnal awakenings)
  • Unrefreshing sleep
  • Nocturia

STOP-BANG questionnaire
The STOP-BANG questionnaire is an efficient and effective tool for assessing a patient’s risk of OSA. This tool is easily accessible online at stopbang.ca. The questionnaire is replicated below. The STOP-BANG questionnaire is shown here for educational purposes only. Dr. Frances Chung and University Health Network own the STOP-BANG. Generally, a higher score indicates a greater likelihood that a patient has OSA.
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OSA risk assessment for the general population
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Patient counseling
If all three screening steps (medical history intake, clinical examination and sleep history) reveal risk factors and symptoms of OSA, it is essential to discuss your findings and their potential implications with the patient. It is crucial to explain the relationship between OSA and any reported or observed systemic conditions, anatomical risk factors or symptoms. Additionally, it is important to counsel the patient on the adverse effects of unmanaged OSA, such as poor systemic health, diminished well-being, reduced quality of life and an increased risk of all-cause mortality.


Referral
After counseling your patient, you should send a referral to the patient’s PCP. List the OSA risk factors identified during your screening and request further evaluation. It’s important to emphasize that dentists cannot diagnose OSA. While we can assist in screening, referral and management, only a medical doctor can make a diagnosis. To clarify what a referral of this nature entails, a sample is provided below. The patient should receive the referral and be advised to contact their PCP as soon as possible. Thoroughly document all findings, patient counsel and the referral in the patient’s chart.

Sample Referral
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Conclusion
Obstructive sleep apnea is widely recognized as a public health crisis because of its high prevalence, predominantly undiagnosed and unmanaged status, and significant health and societal costs. Dentists have a unique opportunity to help alleviate this crisis by implementing a routine OSA screening and referral protocol. Reviewing the patient’s medical history and performing extraoral and intraoral soft and hard tissue examinations are essential for identifying comorbid systemic conditions and predisposing anatomy. This process will also require a discussion of the patient’s sleep history and symptoms. A validated OSA screening tool, such as the STOP-BANG, can also be utilized. Patients identified as at risk for OSA should be counseled and referred to their primary care provider for further evaluation. After a patient is diagnosed with OSA and with adequate training in dental sleep medicine, the general dentist can also participate in managing the patient’s OSA. This topic will be introduced in Part II of this CE series.

References
1. Veasey, Susan C., and Ilene M. Rosen. “Obstructive Sleep Apnea in Adults.” The New England Journal of Medicine, vol. 380, no. 15, 2019, pp. 1442–49.
2. Frost & Sullivan. Hidden Health Care Crisis Costing America Billions: Underdiagnosing and Undertreating Obstructive Sleep Apnea Draining Healthcare System. American Academy of Sleep Medicine, 2016, www.aasmnet.org/ sleep-apnea-economic-impact.aspx.
3. Faria, A. et al. “The Public Health Burden of Obstructive Sleep Apnea.” Sleep Science, vol. 14, no. 3, July–Sept. 2021, pp. 257–65, doi:10.5935/1984-0063.20200111.
4. American Dental Association. Policy Statement on the Role of Dentistry in the Treatment of Sleep-Related Breathing Disorders. 2019, www.ada.org/-/media/project/ ada-organization/ada/ada-org/files/resources/library/ oral-health-topics/ada_2019_policy_role_of_dentistry_ sleep_related_breathing_disorders.pdf.
5. American Academy of Dental Sleep Medicine, and American Academy of Sleep Medicine. Policy Statement on the Diagnosis and Treatment of Obstructive Sleep Apnea. 2017, aasm.org/resources/pdf/aadsmjointosapolicy.pdf.
6. Ramar, Kannan, et al. “Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015.” Journal of Clinical Sleep Medicine, vol. 11, no. 7, 2015, pp. 773–827.
7. Chung, Frances, et al. “STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea.” Anesthesiology, vol. 108, 2008, p. 812.

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Author Bios
Dr. Stephanie Dennison Dr. Stephanie Dennison is a general dentist and clinical assistant professor in the Department of Comprehensive Dentistry at the University of Maryland School of Dentistry (UMSOD). She earned her DDS from UMSOD in 2015 and her AEGD from NYU Langone Medical Center in 2016. She worked with the National Health Service Corps, providing comprehensive dentistry at federally qualified health centers in Maryland until 2021. She is a Fellow of the Academy of General Dentistry and a certified dentist with the American Academy of Dental Sleep Medicine. Dr. Dennison currently practices dental sleep medicine at the UMSOD faculty practice and teaches dental sleep medicine lectures to hygiene and pre-doctoral students at the school.


Dr. Larry Cohen Dr. Larry Cohen earned his DDS degree at the Baltimore College of Dental Surgery, University of Maryland (UM), in 1980. He is an assistant professor in the Department of Dental Public Health at the University of Maryland School of Dentistry. In June 2012, Dr. Cohen began the UM FDSP Sleep Medicine Practice. He lectures third-year dental students on sleep medicine and has also presented to various study clubs and dental meetings within the community, as well as to groups at the university on this topic. Dr. Cohen is a member of the Maryland Sleep Society.


Dr. William Jacobson William Jacobson, DMD, MPH, is a general dentist, clinical assistant professor, curriculum consultant and the author of the “Clinical Dentistry Daily Reference Guide,” a book designed to assist dental students and dentists with daily decision-making in a variety of clinical scenarios. The book is available on Amazon. Website: williamjacobson.net

 
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