How can Dentists Help?
Dentists play a pivotal role in the identification and treatment of obstructive sleep apnea. They see around half the population every year and are well placed to identify oral signs and symptoms.
Dentists can easily screen their patients, often starting a conversation with a simple question like “Do you snore?”.
Dentists are also responsible for one of the two leading treatments for obstructive sleep apnea, mandibular advancement devices (MADs). After patients are diagnosed with OSA by a physician, the dentist will fit and adjust the MAD but also carefully monitor potential dental side effects and collaborate with the physician to confirm ongoing treatment effectiveness. This can be highly rewarding work for a dentist; an opportunity to treat a debilitating medical condition and to change patients’ lives.
There are vast numbers of patients in need of diagnosis and treatment (Figure 4) but current secondary care infrastructure is inadequate to meet the need. The latest estimates suggest that there are nearly 80 million people in USA alone with mild to severe OSA2 but only ~6 million have been diagnosed4. This means that each of the ~7,500 board-certified sleep specialists in USA5 would need to identify and treat an average of 10,000 new patients from their local population to successfully meet the public health need. Dentists can significantly reduce this backlog by screening and treating patients in their practices.
Common signs and symptoms of OSA include:
- Loud snoring that disturbs others
- Daytime sleepiness
- Drowsiness while driving
- Frequent waking and/or need to urinate at night
- Choking or gasping during sleep
- Morning headaches
- Irritability and depression due to sleepiness and fatigue
- Elevated blood pressure that is difficult to control
The American Academy of Sleep Medicine (AASM) recommends asking all adults if they are dissatisfied with their sleep or have daytime sleepiness as part of routine health evaluations. Validated questionnaires are used to make a first screening assessment of patients suspected of obstructive sleep apnea. These include:
Epworth Sleepiness Scale (ESS)
Simple home testing devices based on the measurement of blood oxygen (oximetry) or peripheral arterial tone (PAT) are also sometimes used by dentists to gain a more objective screening result.
After screening a patient, taking their medical and dental history and completing an oral exam, dentists will refer patients who snore or are suspected of having OSA to a sleep centre, sleep physician or sleep testing service (Figure 5).
Figure 5: Typical pathway for patients screened and treated for snoring or obstructive sleep apnea by dentists (varies by country).
AASM and AADSM recommend that a diagnostic assessment should be conducted by a board-certified sleep physician for all patients suspected of having OSA and these evaluations are increasingly conducted using at-home diagnostic and telemedicine techniques. This means that a patient initially screened by a dentist can often be assessed quickly by a physician before returning to the dentist for treatment with a MAD if appropriate.
The diagnostic assessment often includes objective testing using a home sleep apnea testing device (HSAT) which measures airflow, blood oxygen, heart rate and thoracic movement. The severity of OSA and excessive daytime sleepiness must be determined before initiating treatment, not least to guide selection of the most appropriate treatment, but also to provide a baseline against which the effectiveness of future treatments can be measured.
If the patient has a complex medical history, it may not be appropriate for them to undergo sleep testing at home and they may need to attend a sleep clinic overnight for a more comprehensive polysomnography (PSG) assessment. This will be determined by the attending medical professional.
OSA severity is often graded according to the average number of apnea and hypopnea events that occur per hour of sleep.
- An apnoea is defined as a decrease in the amplitude of the respiratory flow ≥ 90% for 10 seconds or more.
- Obstructive Sleep Apnea is a mechanical problem that implies persistent respiratory efforts.
- Central Sleep Apnea is a neurological condition, that implies the absence of respiratory efforts.
- Mixed Apnea is a neurological condition followed by a mechanical problem. It implies the absence of respiratory efforts followed by persistent respiratory efforts.
- An obstructive-hypopnoea is defined as:
- a decrease in the amplitude of the respiratory flow ≥ 50% of at least 10 seconds
- or a decrease in the amplitude of the respiratory flow ≥ 30% of at least 10 seconds
- with oxygen desaturation of at least 3%
- or micro awakenings measured by electroencephalogram
- or automatic micro awakenings that can be linked to an increase of the pulse of at least 5 beats per minute.
An apnea-hypopnea index (AHI) measures sleep apnea severity. AHI is calculated by adding together the number of apnea and hypopnea events and dividing by the number of hours of sleep.
|Apnea-Hypopnea Index (AHI)1|
|Mild Sleep Apnea||AHI of 5 to 15|
|Moderate Sleep Apnea||AHI of 15.1 to 30|
|Severe Sleep Apnea||AHI > 30|
Central sleep apnea (CSA) is another SDB condition with similar symptoms to OSA but is not caused by an obstructed airway. CSA is a relatively uncommon central nervous system disorder in which the body’s neurological trigger to breathe during sleep does not function correctly. Mixed sleep apnea (MSA) is a combination of OSA and CSA.
It is important to rule out CSA as part of the diagnostic assessment before treating a patient with a device that acts on an obstructed airway.
Treatment guidelines vary by country, depending on local policies and reimbursement rules. CPAP, MADs and lifestyle changes are the primary treatments recommended for snoring and obstructive sleep apnea. For more information about local practices, see the Useful Resources and Recommended Reading.
Starting Out in Dental Sleep Medicine?
The scale of the opportunity to improve lives with oral appliance therapy (OAT) is considerable.