Snoring and sleep apnea: Are they a nuisance or disease continuum?

Obstructive sleep apnea (OSA) is a debilitating and often life-threatening sleep disorder and an estimated 800,000 patients are being diagnosed with OSA per year in the United States while approximately only 10 percent are being treated.

Primary care practices are not actively screening patients for OSA, which leaves a large void in the number of patients being identified with this killer disease. OSA has directly been linked through numerous research papers to co-morbidities such as stroke, heart disease, hypertension, impotence and diabetes.

For those patients who have been diagnosed and have had continuous positive airway pressure (CPAP) recommended, some may be intolerant of the therapy and are currently going untreated There are millions of patients who need treatment, including those who cannot tolerate their CPAP machines and are looking for alternatives.

The dental practice is a prime portal to not only screen and identify patients at risk, but also to offer clinically proven therapy with oral appliances.

How to implement oral appliance therapy

It starts with education for the dentist and the dental team. Currently there are many continuing education courses available on the topic of dental sleep medicine and oral appliance therapy, and these are usually two- to three-day courses with subsequent workshops and follow up that is essential. I must emphasize, in order to be successful with implementation, the entire team needs to be involved — dentist, hygienist, assistants and front desk staff.

Following the education, the implementation process begins, which involves asking questions, observing, communicating, initiating systems and offering solutions. The questions should start at the front desk when a patient checks in for their recall appointment. The following questions should be added to your patient history update form:

• Have you been told you snore?
• Are you excessively tired during the day?
• Have you ever had a sleep study?
• Have you been diagnosed with sleep apnea?
• Do you wear a CPAP?

If a patient answers yes to any of these questions, the conversation should be picked up by the hygienist. There are also some telltale clinical signs to look for in these patients such as wear facets (bruxing), periodontal disease, a large neck, obesity, scalloped large tongue, red and inflamed uvula and enlarged tonsils.

On identifying any of these clinical signs, the patient should be directed to fill in a questionnaire called the Epworth Sleepiness Scale. This will identify how “sleepy” the patient is in his or her regular daily routine.

It is likely that patients will tell you “Oh, I just snore when I am tired, I do not have sleep apnea.” However, how would the patient know this if he or she hasn’t been tested? Snoring is the beginning of a disease continuum that will develop into apnea if therapy is not initiated. Apnea will get worse with age, bad diet, weight gain and an unhealthy stressful, lifestyle, which these days can be so common. Unfortunately, many people do not realize that they suffer from sleep apnea unless someone else brings it to their attention.

Following the screening process, a dentist cannot diagnose OSA. The gold standard in care is to refer your patient to a sleep laboratory for a diagnostic sleep study known as a polysomnogram (PSG). This is where you will start to build a mutual referral relationship with your local laboratory and reporting sleep physician.

The multidisciplinary referral pathway should be that you refer your patients for a diagnosis and — providing the results fall within the American Academy of Sleep Medicine (AASM) guidelines for oral appliance therapy, mild to moderate apnea with no co-morbidity — the patient should be referred back to you with a prescription for an oral appliance. This is important for reimbursement too. Oral appliances are also recommended for severe OSA patients if they cannot tolerate their CPAP, although they should always try CPAP first.

Home sleep testing (HST) is becoming more popular and there are companies that offer an interpretation service for patients who will not or cannot to go to a sleep laboratory. There are a wide range of HST devices available to the dental market that can be used for screening, diagnosis (providing they have a certified physician interpret the report and sign off on the treatment recommendation) and the main function in the dental office where it is used to check the effectiveness of the oral appliance therapy and ongoing efficacy.

Once you have a diagnosed patient who is dentally appropriate for oral appliance therapy, you are ready to do a full patient examination, evaluation and work up, including impressions and a bite registration incorporating protrusive and vertical dimension. It would be at this stage that you check their medical insurance and benefits to see if they are covered for this type of treatment.

There are numerous custom fitted oral appliances available on the market, all with varying degrees of efficacy, patient comfort and cost. Consider fabricating and dispensing only FDA-cleared devices when treating OSA in order to secure insurance reimbursement because oral appliance therapy is covered by medical insurance not dental insurance.

Medical billing is becoming a more common necessity in the dental practice for a variety of treatments and procedures. The learning curve and process of medical billing and cross coding can be somewhat consuming, however, there are software solutions available and also companies that will handle the entire process for you which is very helpful, especially for those just getting started.

Once a patient is fitted with an oral appliance, a follow-up protocol is essential in order to ensure that the appliance is adjusted to the optimum position whereby snoring is eliminated and the apnea is reduced significantly. Initially this is done with an HST device and ultimately, when efficacy has been achieved, refer the patient back to the sleep laboratory for a sleep study (PSG).

The HST and PSG results should correlate well, which gives the sleep physician confidence that oral appliances are proving effective, and in some cases a good alternative, to CPAP.

Oral appliance therapy can be truly life changing for these patients and being able to change the quality of someone’s life is extremely powerful and rewarding. I have seen many tears and hugs from grateful patients who didn’t even realize how bad they felt until they started to feel the benefits of their treatment.

In summary, a large part of this treatment can be performed by the hygienist working closely with the dentist and incorporating a multidisciplinary approach. Dental sleep medicine is a substantially rewarding practice and our country is in desperate need of more awareness and treatment options.

Editorial note: This article originally appeared in Hygiene Tribune U.S. Edition, Vol. 4 No. 7, July 2011. A complete list of references is available from the publisher.

About the author

Ashley Truitt, RDA, BBA, has been in the dental industry for the past 25 years. She is the director of Dental Sleep Medicine USA and owner/director of Dental Sleep Medicine Worldwide, an education and consulting organization dedicated to the advancement and awareness of sleep apnea in the dental office. Contact Truitt at atruitt@dsmworldwide.com or +1 940 395 4555.