How dentists who treat snoring and sleep apnea can save marriages and lives

Snoring is extremely common in our society as it has been estimated that 60 percent of men snore and 40 percent of women over age 50 snore. Snoring occurs when there is a partial obstruction of the airway, which causes the palatal tissues to vibrate. Snoring is a serious social problem for the bed partner and adversely affects many relationships.

I treat many patients where snoring is a significant negative factor in their lives. Some studies report that the bed partner’s sleep is seriously affected by as much as one hour per night, which can have a negative effect on their health as well, due to their lack of adequate sleep. (Fig. 1). This is similar to the negative health issues associated with second hand smoke.

USA Today reported that 27 percent of couples over age 40 sleep in separate bedrooms. I think there is a direct correlation between this and the incidence of snoring. As the incidence of obesity continues to increase in our society these numbers are going to continue to increase.

Snoring: tongue partially blocks the airway

Snoring (Fig. 2) has usually been regarded as a social problem with minimal adverse health affects. However, a study in Sydney, Australia, involving 110 patients who snore found that heavy snoring significantly increases the risk of carotid atherosclerosis and their risk factor was independent of obstructive sleep apnea. It appears that the vibrations on the pharyngeal walls are transmitted to the walls of the carotid artery¹.

Ultrasound was used to measure the amount of plaque in the carotid arteries. The conclusion was that the prevalence of carotid atherosclerosis was 20 percent with mild snoring, 32 percent with moderate snoring and 64 percent with heavy snoring. Therefore, patients must be made aware of this important fact so that they can find a solution before the increase in atherosclerosis in their carotid arteries can cause more cardiovascular complications.

Sleep apnea (Fig. 3) is a medical disorder that can only be diagnosed by a sleep specialist in a sleep clinic. The patient must have an overnight sleep study called a polysomnogram, which is evaluated by the sleep specialist. Many sleep specialists prefer to prescribe the CPAP (continuous positive air pressure) device to treat obstructive sleep apnea and do not appreciate the effective role that oral appliances can provide for patients who have mild or moderate OSA (obstructive sleep apnea) or patients who cannot tolerate the CPAP device.

A significant breakthrough occurred for the dental profession in 2006. In the January issue of the medical journal Sleep, the American Academy of Sleep Medicine (medical sleep specialists) issued guidelines stating that for patients with mild to moderate obstructive sleep apnea the oral appliance was the number one treatment option. The guidelines also stated that oral appliances were a viable option for treatment for patients who do not respond to weight loss or have tried the CPAP device and were unable to tolerate it.

The diagnosis for OSA is made using an AHI (Apnea – Hypopnea Index). The diagnosis is made during an overnight sleep study in a hospital or private sleep clinic. This sleep study is known as a PSG (polysomnogram). The number of apneic and hypopnic events are recorded as follows:

• Apnea: A cessation of breath for 10 seconds or more.
• Hypopnea: The blood oxygen level decreases 4 percent 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.

Three treatment options for Obstructive Sleep Apnea

• Oral appliances.
• CPAP device (continuous positive air pressure).
• Surgical removal of structures causing the obstruction.

Once the patient has gone for the sleep study and the AHI has been determined, then the treatment options as listed above must be explained to the patient. Clinicians must distinguish between mild, moderate and severe OSA.

Patients that are diagnosed with severe OSA should be encouraged by the dentist and sleep specialist to wear the CPAP device since this is considered to be the gold standard for the treatment of severe OSA. The CPAP device delivers oxygen to the patient through a mask, which fits over the nose, or over the nose and mouth, via an air compressor and a humidifier. The CPAP device is effective in opening the airway as the air pressure is gradually increased during the follow-up sleep study (PSG). The air pressure successfully displaces the tongue, uvula and soft palate and allows an adequate amount of oxygen to enter the lungs.

When the patient wears the CPAP and the air pressure is correct, it is extremely effective in eliminating OSA. Patients that are happy with their CPAP devices should not be encouraged to replace them with oral appliance therapy. Oral appliances are mainly to be used for patients who cannot tolerate the CPAP device or who have mild to moderate OSA.

The majority of patients who come to my office are either encouraged to seek a solution for their snoring problem or because they were diagnosed with sleep apnea (OSA) and were unable to wear the CPAP device. The statistics on the success of the CPAP device vary greatly according to what articles you read, but the consensus is that approximately 60 – 70 percent of patients are not wearing it after one year. This means there is a tremendous opportunity for dentists to try and relieve the snoring and OSA with oral appliances.

Patients will sometimes ask you about oral appliances that they see advertised on the Internet. Most of these appliances are a “boil and bite” type and put the jaw in only one position. They cannot be adjusted and are often ineffective. The other important fact is that one device that is advertised, called “Pure Sleep,” clearly states that it is not designed to treat patients with TM dysfunction or sleep apnea. The company is correct. No one can legally treat sleep apnea unless a diagnosis has been made by a medical professional, usually a sleep specialist. Therefore, the majority of patients do not qualify for these Internet devices. The other major problem with these “Internet devices” is that there is no follow-up sleep study to determine the efficacy of the appliance in treating OSA which is a serious and indeed life-threatening medical disorder.

After my patients are properly educated, they are not interested in any appliance that will not solve their serious health issue, which is obstructive sleep apnea. My patients who have tried these Internet appliances tell me that they are not nearly as comfortable as the custom oral appliances fabricated for them at our office.

The diagnosis of OSA can only be made by medical practitioners, such as sleep specialists or ENT specialists. Dentists have one of the solutions for treating this medical disorder but must learn to work with their medical colleagues to make the system work for the benefit of the patients. OSA is an extremely prevalent disorder with some serious health consequences.

Some facts that health care professionals need to be aware of include the following:

Co-Morbidity Correlations with Obstructive Sleep Apnea

• Hypertension: 40 – 50 percent.
• Coronary heart disease: 34 percent.
• Congestive heart failure: 34 percent.
• Diabetes: 65 percent.
• Erectile dysfunction: 50 percent.
• Renal disease: 50 percent.
• Fibromyalgia: 80 percent.
• Nocturnal strokes: 84 percent.

There is also a high correlation between patients who have GERD (gastroesophageal reflux)² and OSA. With regard to diabetes, excessive apneic events affect the production of insulin, which encourages the onset of Type 2 diabetes³. These apneic events also affect the permeability of the endothelial lining of the arteries. This increases the buildup of plaque in the arteries and 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 strokes⁴.

To assist practitioners in the diagnosis of OSA, we need to focus on airway obstruction in three areas: nasal, oropharyngeal and hypopharyngeal.

1. Nasal Obstruction

Prior to treatment, clinicians must determine whether or not there are any nasal obstructions that would interfere with the patient’s ability to breathe through their nose. If the patient is a chronic mouth breather, the patient should be referred to an ENT specialist to check for a deviated septum, enlarged turbinates, polyps or other nasal obstructions. A determination must be made whether or not the nasal mucosa is swollen due to allergies that might cause a nasal obstruction⁵.

In our office, we have a diagnostic device known as a rhinometer⁶, which is an initial screening device to determine if there is a nasal obstruction in either nostril. The rhinometer is an accurate, non-invasive device which evaluates the potential obstruction by sending sound waves up the nose and any obstructions are recorded on a computer⁷.

This evaluation of the nasal cavity is also important if the sleep specialist decides to use the CPAP device to force air through the nose. Obviously, if there is a nasal obstruction, the pressure would have to be much higher on the CPAP device. The acceptance of the CPAP treatment is better when the pressure is lower. Therefore, an evaluation of a patient’s nasal airway is an important prerequisite to a successful oral appliance or CPAP therapy⁸.

The two X-rays pictured are para nasal sinus tomogram X-rays of the nasal cavity. The pre-treatment x-ray (Fig. 4) shows enlarged turbinates severely obstructing the airway (black area). The patient had an AHI 76, which is severe obstructive sleep apnea (OSA)

The post-treatment X-ray (Fig. 5) shows the naval cavity after nasal surgery involving a ressection of the inferior turbinates. Clearly the size of the airway (black area) has significantly increased. There was a 50 percent improvement in the patient’s sleep apnea, AHI 32. Possibly now that patient should be offered an oral appliance to move the tongue forward to open up the airway which hopefully would further reduce the AHI and improve the patients’ health.

2. Oropharyngeal Obstructions

Prior to the fabrication of the oral appliance or CPAP therapy, an evaluation must be done of the oral cavity to check for obstructions. The areas of concern would be enlarged tonsils or adenoids (Fig. 6), enlarged uvula (Fig. 7), large tongue (Fig. 8), large mandibular tori, excess tissue in the area of the soft palate, or enlarged torus palatinus. Patients with narrow maxillary arches and high palates are also more susceptible to snoring and OSA. Oropharyngeal obstructions must be surgically corrected prior to oral appliance or CPAP therapy.

3. Hypopharyngeal Obstructions

Oral appliances are most effective when there are no nasal or oropharyngeal obstructions and the problem is behind the tongue in the area of the throat. Class II skeletal patients with retrognathic mandibles (Fig. 9) are the patients that are more likely to have hypopharyngeal obstructions.

Their lower jaws are already retruded, which subsequently causes their tongues to be retruded. This is particularly serious when the patient sleeps on their back. The tongue falls back further and blocks the airway. If the tongue partially blocks the airway, the patient snores. If it completely blocks the airway for 10 seconds or more, for more than six times an hour, the patient is diagnosed with OSA. The main function of the oral appliance is to move the lower jaw forward, increase the posterior vertical dimension and, subsequently, move the tongue forward and open up the pharyngeal airway.

The pharyngometer is a diagnostic device which is utilized in our office to diagnose the size of the airway during the daytime as well as nighttime⁹. It is utilized at the initial appointment to check the patient’s normal airway (daytime) and the collapsed airway (nighttime). To assess the size of the collapsed airway at night, the patient is instructed to exhale all the air from their lungs and a measurement of the airway is taken.

The normal size of a collapsed airway is 2.0 cm. Patients with OSA usually have a much smaller collapsed airway. Bite registrations in different positions are taken to try and see how large the airway may be increased. Our office uses a system called Airway Metrics¹⁰, which consists of a number of plastic bite gigs to help measure the size of the airway in different positions. Various bite registrations are taken including some which may be end to end and open 6 mm, 1 mm protrusive and open 4 mm, end to end and open 4 mm, etc.

By moving the mandible forward at different vertical heights, we determine if the oral appliance will open the airway in that position significantly. In most cases, when a bite registration reveals that the airway opens significantly, when the oral appliance is fabricated in that position, the treatment is usually successful.

The results using different bite registrations are not always successful if the patient has a physiologically narrow airway or has excessive swelling in the area of the uvula and soft palate due to excessive snoring or smoking. The pharyngometer helps to give the clinician a starting position to fabricate the oral appliance. It is important to select a position that is comfortable for the patient. It is advisable then to use an oral appliance such as a Somnodent, EMA, Modified Herbst, SUAD or TAP Appliance that can be adjusted to move the mandible slowly forward to reduce the snoring and OSA¹¹.

As mentioned previously, airway obstructions in the nasal and oropharyngeal (mouth) areas must be eliminated prior to the fabrication of the oral appliance. When oral appliances are utilized in these cases, they are highly effective. Our success rate with oral appliance therapy is over 90 percent. I routinely evaluate my patients’ nasal airways (rhinometer), oropharyngeal and hypopharyngeal airways (pharyngometer) prior to treatment. If you cannot properly diagnose the problem, your treatment will be less successful.

Patients much prefer to wear an oral appliance rather than the CPAP device. However, for severe OSA, the CPAP is the treatment of choice. If a patient is unable to wear the CPAP and they have severe OSA, or if they have mild to moderate OSA, the oral appliance is the treatment of choice.

I recently spoke with a sleep specialist in Nevada who estimated that 18 to 30 percent of the population is suffering from mild, moderate or severe OSA. Whether you live in the United States, with a population of 309 million, or in Canada, with a population of 34 million, this means there are large numbers of patients who are suffering from these sleep disorders who desperately need treatment.

If you start helping these patients achieve a higher level of health and extend their lifespan, you will feel better about your practice and yourself. We are presently treating approximately 10 – 15 patients per month at $3,000 per case. Obviously, this can positively affect your income while you are helping patients become healthier. In Canada, most insurance companies will pay for the CPAP device but will not pay for oral appliances. In the United States, many medical plans will pay for both CPAP and oral appliances.

I strongly believe that 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 (OSA) are snoring and excessive daytime sleepiness.

To assist dentists in determining the level of sleepiness, Dr. Murray Johns, Epworth Hospital in Melbourne, Australia, introduced the Epworth Sleepiness Scale in 1991 (Fig. 15). I recommend that any patient who snores should complete this questionnaire. It is also advisable to have the bed partner complete the form as well. Our experience has been that many patients, particularly males, underestimate the extent of their daytime sleepiness and the report from the bed partner is usually more accurate.

The Epworth Sleepiness Scale is extremely helpful in determining the extent of the daytime sleepiness, which is one of the main symptoms of obstructive sleep apnea (OSA). This scale determines how likely the patient is to fall asleep in certain situations. A 0 means they would never doze off, 1 means a slight chance of dozing, 2 means a moderate chance of dozing, and 3 means a high chance of dozing in various situations. The number of patients with daytime sleepiness, especially those over age 50, will be significant.

I had one dentist in my sleep course, involved in a group practice, go back to his office and give the Epworth Sleepiness Scale to all patients who snored. Remember, snoring is one of the main symptoms of obstructive sleep apnea. Within three weeks, he had 50 patients who scored high on the Epworth Sleepiness Scale and who were therefore candidates for oral appliances or the CPAP device. It is important to educate the staff, including receptionists, dental assistants and hygienists, regarding the diagnosis and treatment of these patients. I find the hygienists are particularly important in conveying the information to patients and asking them to complete the Epworth Sleepiness Scale.

For any patient who has an Epworth Sleepiness Scale higher than 8, it is recommended to seek medical attention in terms of a sleep study in order to diagnose the presence or absence of OSA¹². Patients who snore but do not have OSA may be treated by the dentist with an oral appliance. Prior to the fabrication of the oral appliance, the dentist must receive a report from a sleep specialist, stating that the patient does not have sleep apnea. When the patient only snores and does not have sleep apnea, no follow-up sleep study is necessary. If the patient is diagnosed with mild to moderate OSA and the sleep specialist and patient agree, the dentist can then fabricate an oral appliance.

After the oral appliance has been adjusted over several months, the patient must have a follow-up sleep study (PSG) to confirm the efficacy of the appliance. It is imperative that the dentist establish a good working relationship with a sleep specialist in the sleep lab if they want to be successful in the field of sleep dentistry.

I advise all dentists who are interested in expanding their practice to educate themselves and their staff as a first essential step. They must contact a sleep specialist to diagnose these patients with a sleep study prior to treatment and then afterward to confirm the efficacy of the oral appliance. Most sleep specialists will welcome the opportunity to work with competent dentists. Once a good relationship has been established, this will result in referrals for patients with mild sleep apnea and who cannot tolerate their CPAP device.

Another excellent diagnostic device that I have found to be very useful in my sleep practice is the Embletta 100, a home sleep study. Patients much prefer this home sleep study compared to the hospital sleep study (polysomnogram). The Embletta 100 cannot be used to diagnose OSA unless it is confirmed by a sleep specialist, but it is useful during the titration or adjustment period for the oral appliance.

Most oral appliances are not 100 percent effective when they are first inserted. The uvula and soft palate tissues can be quite swollen due to snoring and/or smoking. As the swelling subsides, the appliance is slowly adjusted to move the mandible and tongue further forward, sometimes taking two to four months.

During the titration period, it is often advisable to test the efficacy of the oral appliance with the home sleep study (Embletta 100)¹³. The advantages of this device are that it is extremely comfortable, accurate and the patient feels that they get a more normal sleep since they are sleeping in their own bed.

The cost is reasonable as the value of the disposables for this home sleep study is only five dollars. Therefore, patients can be given several economical and convenient sleep studies to ensure that the oral appliance is effective in eliminating the snoring and OSA.

The Embletta 100 home sleep study device is more acceptable to the medical profession and sleep specialists because it has a nasal cannula, pulse oximeter and chest and abdominal straps. Some sleep specialists in the sleep centers have utilized the Embletta 100 for patients who are unsuccessful with the polysomnogram (PSG).

Some patients do not like the polysomnogram due to the odor of the electrodes, suffer from claustrophobia, or cannot sleep in a strange bed with 16 electrodes attached to their body. Most patients feel that they get a more accurate sleep study when they sleep in their own bed with the Embletta 100 home sleep study device.

In Europe, most of the studies are home sleep studies due to the significant cost savings as compared to the cost of the polysomnogram sleep study in private sleep clinics or hospital sleep clinics.

It is extremely important that you successfully titrate (adjust) the oral appliance with the Embletta 100 home sleep study device prior to sending the patient for a PSG to a private or hospital sleep clinic. This will prove to the sleep specialists and the E.N.T. specialists that oral appliances are effective in reducing snoring and obstructive sleep apnea. The Embletta 100 will help you to achieve these objectives. This will result in you having more patients referred to you by the sleep specialists and ENTs for treatment with oral appliances.

The Embletta 100 is the home sleep study that is reputed to be number one in Europe for the past eight years. It has been well researched and the results correlate very accurately with the polysomnogram at the sleep clinics.

The patient is instructed to return to the sleep center for a follow-up PSG, with the oral appliance, to confirm that the appliance is effective. Insurance companies and patients much prefer this approach. You cannot expect insurance companies to pay for three or four sleep studies. The sleep specialists are usually impressed with the results and will, therefore, be encouraged to refer more patients to your office who cannot wear the CPAP or have mild to moderate OSA and request an oral appliance.

Be advised that it is critical for the successful treatment of our patients to work closely with the medical profession. Reports must be sent to the patient’s primary care physician to keep them informed of their treatment. Dentists should also inform the sleep specialists that patients with severe OSA must be referred for treatment with the CPAP or BiPAP devices. 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.

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 afterward 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 them¹⁴.

Recently in the United States, Medicare has started to pay for patients with obstructive sleep apnea. Medicare is willing to pay for a CPAP device but they want confirmation on compliance. They do not want to pay for the device if it is not being utilized on a regular basis by the patient. The newer devices can be integrated with the telephone line and the data is analyzed by a third party to verify compliance. If there is no compliance, Medicare will not pay for the device.

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 (Fig. 10) and could not tolerate the device, were never contacted again by either the sleep specialist or the Durable Medical Equipment company. Some of these patients already have co-morbid factors such as high blood pressure, cardiovascular disease, Type 2 diabetes, GERD, etc. and their health continues to deteriorate. The system certainly needs to be improved for the benefit of these patients.

Dentists and staff who are interested in pursuing their education in sleep disorder dentistry (snoring and sleep apnea) should be encouraged to take some courses. One suggestion would be to consult the website www.rondeauseminars.com for sleep courses with experienced clinicians and lecturers offered in different locations in Canada and the United States. In the near future, some of these sleep disorder dentistry courses will also be conveniently available on the Internet.

I would also encourage interested dentists to join the American Academy of Dental Sleep Medicine. This organization offers courses that would help practitioners accumulate new and important information on sleep disorders such as obstructive sleep apnea.

Oral Appliances

Oral appliances (Fig. 11) are extremely effective in eliminating snoring and OSA, particularly in the patients with mild to moderate OSA¹⁵. They function by moving the lower jaw and consequently the tongue forward to open up the airway¹⁶. They hold the lower jaw forward when the patient sleeps on their back, which keeps the airway open all night. The literature is replete with articles regarding the effectiveness of different oral appliances¹⁷. It should be stressed to the patient that oral appliances are extremely comfortable to wear.

Three different oral appliances that are utilized to prevent snoring and OSA include Somnodent, EMA and Suad Appliance. The appliances all work essentially the same way by gradually moving the lower jaw forward in small increments and increasing the vertical dimension which ultimately increases the size of the pharyngeal airway.

In the case of the Somnodent appliance (Fig. 12), the mandible is gradually and painlessly moved forward by turning the two side screws. The EMA appliance is adjusted by changing the straps on the side of the appliances. The SUAD appliance is adjusted by adding plastic shims (like washers to the sides of the appliance, which gradually advances the mandible comfortably. When a thorough examination of the nasal airway and oropharyngeal airway (mouth area) reveals that there are no obstructions, oral appliances are extremely effective. The reason for this is that in approximately 66 percent of the cases the obstruction occurs at the base of the tongue.

It is imperative that dentists learn to treat patients with mild to moderate OSA and those who cannot tolerate the CPAP device¹⁸. There are thousands of patients who have been diagnosed with OSA and cannot wear the CPAP. The health of these patients is continuing to deteriorate and their life expectancy shortened and the dental profession holds the key to their treatment.

I have treated many patients with severe OSA who could not wear the CPAP device and successfully reduced their apneic events below five times 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 attack, stroke and Type 2 Diabetes¹⁹.

Opportunity for dentists to make highways safer for everyone

Crashes involving commercial truck drivers are a significant health hazard causing thousands of deaths and injuries each year, with driver fatigue and sleepiness being the major causes.

In the American Journal of Respiratory and Critical Care Medicine it was reported in 2004 that as many as 41 percent of the major crashes of commercial vehicles were due to driver sleepiness. In 2001 large trucks were involved in 429,000 crashes and nearly 5,000 were fatal²⁰. Due to the obesity epidemic today, if the study was done in 2010 the incidence, I am certain, would be much higher indeed.

Today there is an increasing awareness that drowsy drivers suffering from obstructive sleep apnea cause more traffic accidents than drunk drivers. Many years ago the laws regarding drinking and driving were not as stringent as they are today. Organizations such as MADD (Mothers Against Drunk Driving) have helped convince the police and driver licensing agencies to send drivers to jail who are guilty of this offence. In the United States and Canada, there is some discussion about mandatory testing for sleep apnea for all commercial truck drivers.

There have been numerous sleep studies done on commercial drivers with results ranging from 12 percent to 80 percent of the drivers being diagnosed with OSA. Obesity and age are two important factors. The older and more obese the drivers, the higher incidence of OSA and in particular, severe OSA.

The problem is one of education and compliance. In one study they found 17 percent of the drivers were diagnosed with OSA. Of the 53 drivers that were confirmed to have OSA only one driver complied with the treatment recommendations²¹. The drivers are obviously worried that if diagnosed with OSA they could lose their drivers license, which is essential for their livelihood. It is important for the medical and dental professions to educate the truck drivers that OSA is a treatable medical disorder. Someone needs to educate them regarding the consequences of not being treated:

• Their own health can be seriously compromised if they do not get the problem resolved. In cases of severe obstructive sleep apnea, life expectancy is reduced by eight to 18 years. They have an increased risk of high blood pressure, heart disease, strokes, Type 2 diabetes and acid reflux.
• If they fall asleep at the wheel they could kill or injure themselves or other drivers or passengers.

Dr Philip Parks, medical director of Lifespan employee health and occupational services, stated, “It is well known that obesity, a leading risk factor for obstructive sleep apnea is on the rise in the United States. Truck drivers with sleep apnea have a seven-fold increased risk of being involved in a motor vehicle crash.”²¹

It has been estimated that as many as 3.9 million licensed commercial drivers in the United States have OSA. As mentioned previously, the problem is that commercial drivers are not educated or motivated to seek treatment for this medical condition.

Is it any wonder when you consider how well the average medical or dental school has educated its students in the past. Many medical schools reported less than one hour of training in sleep disordered breathing in four years of medical school.

I am encouraged by the fact that this is changing in more recent medical school curriculums. Most dental schools do not teach anything in this extremely important subject. Based on the above, Dr Park’s conclusion was that “It is possible that many of the 14 million truck drivers on American highways have undiagnosed and untreated sleep apnea.”

Obviously this problem is extremely serious and needs to be addressed immediately in order to save more lives and prevent injuries. The employers of truck drivers in my opinion should encourage all of their drivers to get an overnight sleep study (PSG) to diagnose the absence or presence of OSA.

Employers must be aware of the liability issues and the potential repercussions that could occur if one of their drivers fell asleep at the wheel while driving one of their trucks that was involved in a fatal MVA (motor vehicle accident). Perhaps dentists involved in sleep disorder dentistry should approach trucking companies in their area in order to encourage them to educate, diagnose and treat their drivers if they have OSA.

One of the main problems today is that if the government ordered all 14 million truck drivers in the United States to be tested for OSA, there are not enough available sleep labs to do the sleep studies. Similarly, there are not enough dentists to treat all the patients. At the present time there are 165,000 dentists in the United States and Canada, of which approximately 1,800 are members of the American Academy of Dental Sleep Medicine. Dentists who take courses now and increase their skill level in this area I think will be extremely busy when the government decides to proceed with mandatory OSA testing for commercial drivers. Commercial airline pilots have mandatory testing now and I think that in the near future you will see this also applied to commercial truck drivers.

While this problem is being solved I would recommend the following:

1. Encourage all your patients who are commercial truck drivers to get a sleep study to see if they are diagnosed with OSA. If they do have sleep apnea, encourage them to get treated.

• Mild to moderate OSA: recommend oral appliances.
• Severe OSA: recommend CPAP as their first option.

Remind them that OSA is a completely treatable medical disorder.

2. Encourage all your patients who snore or who have a score higher than 7 on the Epworth Sleepiness Scale to have a sleep study to diagnose the presence of OSA.

3. If you are on the highway, particularly at night, do not drive too closely to trucks due to the high incidence of truckers with OSA which causes significant sleepiness and more accidents.

Conclusion

The prevalence of obstructive sleep apnea is exceedingly high in all first world countries including the United States and Canada due to the obesity epidemic. An estimated 25 percent of males and 9 percent of females will develop OSA (obstructive sleep apnea) in their lifetime²². I believe it is the obligation of the dental profession to learn how to diagnose and treat these patients. As I mentioned previously, there are only three ways to treat OSA: oral appliances, CPAP and surgery.

While some patients may need a combination treatment, oral appliances are certainly the preferred option chosen by most patients (non-invasive, reversible). The problem with the CPAP and BiPAP devices is that the compliance rate is only 60 percent after one year²³. Therefore, literally thousands of patients are seeking alternate forms of treatment. Compounding this enormous problem is that it is estimated that 85 percent of the patients with OSA are undiagnosed.

Dentists who wish to treat this medical disorder seriously must utilize various sleep health questionnaires, including the Epworth Sleepiness Scale. I recommend interested dentists to take courses and learn how to utilize various diagnostic devices, including the rhinometer, pharyngometer and Embletta 100 as previously discussed. Patients with whom you are suspicious of possible OSA must be referred to their primary care physicians and sleep specialists for overnight sleep studies in order to make a diagnosis. For mild to moderate cases of OSA, oral appliances are the first treatment option.

The compliance rate for oral appliances is extremely high in our office at over 95 percent. Many of the patients who fail with CPAP are not even made aware by some sleep specialists and medical doctors of the existence or efficacy of oral appliances. It is the dental professions responsibility to help educate our medical colleagues regarding oral appliances and also to work with them to help solve obstructive sleep apnea which has truly become a health epidemic.

 

EPWORTH SLEEPINESS SCALE

The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire and widely used by sleep professionals in quantifying the level of daytime sleepiness.

(Johns, M.W. “A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale.” Sleep 14 (1991): 540-545.)

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = Would never doze 2 = Moderate chance of dozing
1 = Slight chance of dozing 3 = High chance of dozing

CHANCE SITUATION OF DOZING

Sitting and reading ______
Watching television ______
Sitting, inactive in a public place (e.g. theatre, meeting) ______
As a passenger in a car for an hour without a break ______
Lying down to rest in the afternoon when circumstances permit ______
Sitting and talking to someone ______
Sitting quietly after lunch without alcohol ______
In a car, while stopped for a few minutes in traffic ______

TOTAL SCORE

• 0-7: It is unlikely that you are abnormally sleepy
• 8-9: You have an average amount of daytime sleepiness
• 10-15: You may be excessively sleepy, depending on the situation, and may want to consider seeking medical attention
• 16-24: You are excessively sleepy and should consider seeking medical attention

 

About the author

Brock Rondeau, DDS, IBO, DABCP, is one of North America’s most sought-after clinicians, who lectures more than 100 days per year. He is a master senior certified instructor for the International Association for Orthodontics, and he is the past president. More than 19,000 dentists have attended his courses and study clubs in the United States, Canada, China, Australia, England and Poland. He has an extremely busy practice limited to the treatment of patients with orthodontic, snoring and sleep apnea and TMJ problems. Dr Rondeau is a Diplomate of the International Board of Orthodontics, and he is a Diplomate of the American Academy of Craniofacial Pain.

References
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