DENTISTRY SAVES TEETH, SLEEP DENTISTRY SAVES LIVES
By Dr. Brock Rondeau, DDS
http://rondeauseminars.com
1-877-372-7625
info@rondeauseminars.com
One of the most serious health concerns in our society today is the presence of obstructive sleep apnea (OSA). The majority of patients with OSA have two main characteristics: i) loud snoring and, ii) excessive daytime sleepiness.
The diagnosis of OSA, a medical sleep disorder, can only be made by a medical practitioners such as a sleep specialist or E.N.T. specialist. Sleep apnea occurs when the tongue falls back and blocks the airway for 10 seconds or longer. Some patients may stop breathing hundreds of times each night which can be extremely detrimental to their overall health, as shown below.
Some facts that health care professionals need to be aware of include the following:
Co-Morbidity Correlations with Obstructive Sleep Apnea
•Hypertension 40 – 50%
•Coronary heart disease 34%
•Congestive heart failure 34%
•Diabetes 65%
•Erectile dysfunction 50%
•Renal diseased 50%
•Fibromyalgia 80%
•Nocturnal strokes 84%
There is also a high correlation between patients who have GERD (gastroesopha-geal reflux) and OSA. With regard to diabetes, excessive apneaic events affect the production of insulin which encourages the onset of type 2 diabetes. These apneaic events also affect the permeability of the endothelial lining of the arteries. This increasing incidence of the buildup of plaque in the arteries increases the chance of cardiovascular complications, such as a heart attack. The weakening of the walls of the arteries increases the susceptibility of rupturing of these vessels which occurs during strokes.
Obstructive sleep apnea is an extremely dangerous health risk. Six out of ten patients over age 40 snore and two out of six have OSA. The other rather alarming fact is that 85% of patients with OSA have been undiagnosed. This means that massive numbers of patients have the problem but are totally unaware of the dangers they are facing in the future if they are not diagnosed and do not receive proper treatment. Since studies have indicated that a patient with severe OSA, left untreated, will die 8 – 10 years earlier than a patient without OSA.
The fact is that patients with severe sleep apnea are definitely at risk to die prematurely and spend many years in poor health with cardiovascular disease, diabetes and possibly strokes. Recently, a woman, age 62, came in to make an appointment for a snoring appliance as her husband had been complaining about the noise for years. She was informed that an oral appliance could not be fabricated without a sleep study to determine the presence or absence of OSA. She was told that most patients who snore have mild, moderate or severe OSA and these conditions can cause heart attacks, strokes, type 2 diabetes, etc. She stated that she had already had two heart attacks and a mild stroke. I then asked her if the medical doctor, cardiologist or neurologist suggested a sleep study to determine whether or not sleep apnea might have contributed to the heart attacks or stroke. She indicated that I was the first to make her aware of this situation.
It is my opinion that a vast majority of the medical and dental profession are not well educated in this area. The fact that only 15% of patients with OSA are diagnosed is indicative of this. The public is also not well informed about the health risks associated with this serious disorder. Most dental schools do not offer courses to help dentists understand the important role they play in the treatment of this disorder. Cardiologists and the medical profession are beginning to see the importance of diagnosing and treating patients with OSA as early as possible in order to avoid future health problems.
My treatment plan for this patient who already had two heart attacks and a mild stroke is to send her for an overnight sleep study. If she has severe OSA, a CPAP device will be prescribed. If she is diagnosed with mild to moderate OSA, an oral appliance will be fabricated and titrated until the snoring and apneaic events stop. To confirm that the oral appliance is effective, the patient will be sent back to the sleep clinic for another sleep study (PSG, polysomnogram). Dentists must confirm that the oral appliance effectively reduces the snoring and OSA.
It is the responsibility of the medical and dental profession to identify patients who have airway obstructions leading to snoring and sleep apnea. The two main signs of obstructive sleep apnea are snoring and excessive daytime sleepiness. To assist clinicians in determining the level of sleepiness, The Epworth Sleepiness Scale was introduced in 1990 by Dr. Murray Johns, Epworth Hospital, Melbourne, Australia. I have enclosed a copy for your information.
I recommend that any patient who snores, as well as their bed partner, complete the Epworth Sleepiness Scale. My experience has been that many patients, especially males, underestimate the extent of their daytime sleepiness.
Any patient with a score of 8 or higher should seek medical attention in terms of a sleep study, to diagnose the presence or absence of OSA. If the sleep study reveals that the patient only snores but does not have OSA, the dentist can legally proceed to fabricate an oral appliance. No follow-up sleep study will be necessary. If the patient has mild or moderate OSA and the sleep specialist agrees, then the dentist can fabricate an oral appliance. As mentioned previously, after the adjustments of the appliance are made over several months, the patient must have a follow-up sleep study to confirm the efficacy of the oral appliance.
The Embletta 100, a home sleep study, is utilized in our office. This is an excellent screening device to determine if the oral appliance has been effective. During the titration (adjustment) phase of the oral appliance, it is often useful to test the efficacy of the oral appliance with the Embletta 100. Patients much prefer the home sleep study to the hospital or sleep clinic (polysomnogram) sleep study. The advantages of the Embletta 100 are that it is extremely comfortable, accurate and this test only costs the dentist five dollars.
Occasionally, we will give the patient 2 or 3 home studies while the appliance is titrated and the lower jaw is slowly moved forward. After the Embletta 100 demonstrates that the oral appliance has effectively reduced the OSA, the patient is sent back to the sleep clinic for a sleep study. The sleep specialists are impressed with this approach and are encouraged to refer more patients to our office who cannot wear the CPAP device or who only have mild to moderate OSA. Dentists have to help to educate specialists regarding their effective rol in treating patients with OSA with oral appliances. It is the role of the dental profession to educate and gain the respect of the sleep specialists by referring patients to them with severe OSA and encouraging them to wear the CPAP device.
In the U.S., Medicare has adopted a policy recently whereby they will not pay for the CPAP device unless there is compliance. Each device has a computer chip which can be transmitted over a telephone line to verify compliance. I believe that all insurance companies will follow this example. It will give clinicians who treat sleep disorders a much clearer picture of the actual compliance rate.
Whatever the statistics say, there are a large number of patients who, for a number of different reasons, cannot tolerate the CPAP device and are looking for an alternative. It is unfortunate that, at this point, neither the DME (Durable Medical Equipment) companies or the sleep specialists are recommending that the patient go to a qualified dentist to fabricate oral appliances when a patient cannot wear the CPAP device. Hopefully, this will change in the future.
The diagnosis for OSA is done using an AHI (Apnea Hypopnea Index). During the overnight sleep study, the number of apneaic and hypopnea events per hour are recorded.
APNEA A cessation of breath for 10 seconds or more
HYPOPNEA The blood oxygen level decreases 4% or more, Cessation of breath for less than 10 seconds
MILD SLEEP APNEA (OSA) 5 – 15 events per hour
MODERATE SLEEP APNEA (OSA) 16 – 30 events per hour
SEVERE SLEEP APNEA (OSA) More than 30 events per hour
There are basically three ways to treat OSA:
1. CPAP (Continuous Positive Air Pressure)
2. Oral Appliances
3. Surgery
Dentists who treat sleep disorders must obviously be knowledgeable in all three areas of treatment and proceed with the therapy that is correct for each individual patient.
In the medical journal, Sleep, January 2006, the American Academy of Sleep Medicine (sleep specialists) made the statement that for patients with mild to moderate OSA (Obstructive Sleep Apnea), the oral appliance was the number one treatment option. The guidelines also mentioned that the oral appliance was a viable option for patient who do not respond either to weight loss or have tried the CPAP device and were unable to tolerate it.
This was a monumental statement by the medical profession that, I believe, validated the importance of the dentist and the use of the oral appliance to help to treat these patients.
It is important to distinguish between mild, moderate and severe OSA. Patients that are diagnosed with severe OSA should be encouraged to wear the CPAP device since this is the gold standard for the treatment of severe OSA. The CPAP consists of a mask which the patient wears over the nose. This mask is attached to a hose connected to an air compressor and humidifier. The CPAP is extremely effective in opening the airway as the air pressure is increased gradually during the polysomnogram (sleep study) until it successfully displaces the tongue, uvula and soft palate. When the patient wears the CPAP and the air pressure is correct, it is extremely effective in eliminating sleep apnea.
Once the patient is diagnosed by the sleep specialist at the sleep clinic, the patient usually returns for a second sleep study when the technician determines what air pressure will be necessary to eliminate the OSA. The more serious the problem and, in some cases, the more obese the patient, the pressure must be increased substantially to obtain the desired result. The lower the air pressure usually results in better compliance. The exception to this would be patients with severe sleep apnea who seem to benefit the most from the CPAP. These patients feel so exhausted prior to wearing the CPAP and feel so refreshed afterwards that their compliance rate is high. My observation has been that patients with mild to moderate OSA are not as compliant. This is where, I believe, the dental profession needs to become involved. If the patient is mild to moderate and there is no necessity for surgery, then the oral appliance fabricated by the dentist is the best option. The fact is that a larger number of patients who are prescribed CPAP devices, cannot tolerate them.
There are several different CPAP and BIPAP devices so patients should be encouraged to try several types until they find one that is acceptable. I am constantly amazed by the fact that patients who were diagnosed with OSA, prescribed a CPAP unit and could not tolerate the device, were never contacted again by either the sleep specialist of the DME company. Some of these patients already have co-morbid factors such as high blood pressure, cardiovascular disorder, type 2 diabetes, GERD, etc. and their health continues to deteriorate. The system certainly needs to be improved for the benefit of these patients.
If oral appliances are effective in reducing OSA in mild and moderate cases of OSA, I believe dentists should be involved in the treatment of patients who fail with the CPAP device. In my opinion, the dental profession has an obligation to treat these patients. If we educate ourselves in sleep disorders, we can save and certainly prolong lives. I have treated many patients with even severe OSA who could not wear the CPAP device and successfully reduced their apneaic events below 5 events per hour, which is normal. This treatment certainly improves their health and prolongs their life by reducing their blood pressure and their susceptibility to heart attacks, strokes and type 2 diabetes.
If general dentists wish to treat these patients, they must take courses in sleep disorder dentistry to become more knowledgeable in this area. Conversely, if they do not wish to treat, they need to at least use the Epworth Sleepiness Scale and refer patients who snore and may have OSA to dentists and sleep specialists who are qualified to treat these patients. I am hopeful that some time in the future, dental schools will start adding this to the curriculum.
To find a Dentist in your area who practices Sleep Dentistry, visit
Sleep Test.
To find a Dentist who uses Advanced Diagnostics and Biometrics in Dentistry, Visit
BioRESEARCH.
