Dental Sleep Medicine
The importance of sleep medicine in dental education and practice
Jeannette DeWyze
Snoring is a common form of sleep-disordered breathing caused by a narrowing and collapsing of the upper airway during sleep. When air flowing between the tongue and soft palate causes the soft palate to vibrate, noise is produced. Snoring is also a common symptom of obstructive sleep apnea (OSA), in which the obstruction is so significant it causes the sleeping individual to stop breathing frequently. The prevalence of OSA has been increasing, with 17% of 50- to 70-year-old men currently estimated to have moderately to severely disordered breathing during sleep.1
Both snoring and OSA have a wide variety of negative effects on health.2 Adverse outcomes that have been associated with untreated OSA include hypertension, coronary artery disease, stroke, atrial fibrillation, congestive heart failure, daytime sleepiness, and increased mortality.3 The condition also has been associated with a higher incidence of motor vehicle accidents. Negative social consequences accompany both snoring and OSA, as they disrupt the sleep of bed partners, whose own risk for cardiovascular disease, in turn, may increase.4
Treatment for Snoring and OSA
The most common approach to treating OSA is the use of continuous positive airway pressure (CPAP). First introduced in 1981,5 this is still the standard of care for OSA.6 However, CPAP machines are obtrusive, and compliance by patients often is suboptimal.7,8
As an alternative, the first oral appliance for OSA was developed in the 1980s. Since then, the Food and Drug Administration (FDA) has cleared more than 100 appliances for the treatment of snoring and OSA.9 Advantages of these devices include the fact that they are less cumbersome and more portable. Some patients tolerate them well, and their effectiveness in treating snoring and OSA has been demonstrated.10 Over time, their clinical use has increased substantially, along with the scientific literature evaluating them.
An oral appliance is a mandibular advancement device that repositions and stabilizes the mandible, while also typically engaging the maxilla.11 Use of this type of device has been found to be effective in the treatment of snoring and OSA.10 According to the American Academy of Dental Sleep Medicine (AADSM), an effective oral appliance is custom-fabricated using digital or physical impressions and models and is not a primarily prefabricated item that is trimmed, bent, relined, or otherwise modified. Oral appliances may or may not be adjustable, incorporating a mechanism to enable changing the position of the mandible over time. Also available to consumers are non-custom “boil and bite” devices, which are primarily prefabricated and usually partially modified to an individual patient’s oral structures. However, custom, titratable appliances are recommended for the treatment of OSA over non-custom devices.12 Another type of device is the tongue retention device, which seeks to keep the airway unobstructed during sleep by holding the tongue forward. Evidence also shows that these devices are usually not as effective as custom, titratable oral appliances due to poor compliance.13
Sleep Medicine and Dentistry
The similarity between the oral appliances used to treat OSA and other appliances commonly fabricated by dentists is one reason that interest in sleep medicine has grown within dental offices. Beyond that, dentists are the perfect care providers to become involved with sleep medicine “because we have a lot of interaction with our patients,” says Gary Radz, DDS, a Denver dentist and associate clinical professor at the University of Colorado School of Dentistry. He got involved with dental sleep medicine approximately 10 years ago because of his own problems with OSA. “Some of what you look for are potential anatomic problems associated with the airway and the back of the throat, things that we see all the time.”
Patients who have difficulty breathing when they’re tipped too far back in the dental chair are likely to have breathing disorders during sleep, as are those who are significantly obese. Other signs of OSA include heavy bruxism, gastroesophageal reflux disease (GERD), and higher Mallampati classifications. Bruxism is a sign because individuals who are experiencing apneic episodes often clench and/or grind the teeth in order to awaken and resume breathing. Acid reflux or GERD is another common symptom because when breathing becomes obstructed and the throat and windpipe muscles tighten, stomach acid may be pushed into the throat and mouth. A Class 3 or Class 4 Mallampati classification is relevant because those classifications indicate the most limited airway openings.
“We see the typical patient twice a year,” Radz notes. “We’ve got a fairly consistent and ongoing health care relationship with those people. It becomes very easy to bring up the subject because for us it’s part of the medical history information that we gather.” Administration of the STOP-BANG Sleep Apnea Questionnaire,14 which measures risk factors for sleep apnea, and the Epworth Sleepiness Scale questionnaire can help confirm a high risk for sleep-disordered breathing.
If that appears to be the case, dentists in some states can send patients home with a sleep-testing unit, a small box that typically records airflow, respiratory effort, brain waves, oxygen levels, and heart rate. The results are then interpreted by a board-certified sleep medicine physician. This data and interpretation provide the foundation for a diagnostic decision by a physician, the only care provider who can legally make a diagnosis. Alternatively, the dentist may refer the patient to a board-certified sleep medicine physician for a comprehensive sleep evaluation, which may involve either a home sleep apnea test or an overnight sleep study in a sleep center. Called a “polysomnogram,” a sleep study involves attaching electrodes to the patient’s body to record brain waves, heart rates, eye and leg movements, and other factors.
Once diagnosis of OSA has been made, the physician may refer the patient back to the dental office to obtain an oral appliance. However, the number of practices that routinely provide oral appliance therapy is limited, in part because dental schools have only recently begun to incorporate sleep medicine into their curricula.
Sleep Disorders in Dental School Education
The Tufts University School of Dental Medicine was the first to incorporate the teaching of sleep disorders into an existing dental school class in 2009, according to Leopoldo Correa, BDS, an associate professor there.
Correa says dental students at Tufts now receive lectures in sleep disorders each of the 4 years they are enrolled. Moreover, in 2013, Tufts created the first US fellowship program in dental sleep medicine; the first fellow graduated in 2015. The University of Texas at San Antonio and the University of California at Los Angeles have mini residencies in the specialty, according to Kathleen Bennett, DDS, president of the AADSM. Bennett says there’s still “a need for increased dental school training.”
The AADSM has thus attempted to fill some of the educational void. Founded in 1991 (as the Sleep Disorders Dental Society), the professional group has since grown to include around 3,000 members. It accredits dental sleep medical facilities,15 and in cooperation with the American Academy of Sleep Medicine, the AADSM recently released a new clinical practice guideline for oral appliance therapy.12 In 1998, the academy established a certification program that in 2004 grew into the American Board of Dental Sleep Medicine. This organization helps set standards for the scope of dental sleep medicine, and to date has granted diplomate status to about 400 dentists. “Awareness is really rising,” says Bennett, who adds that another 80 or so candidates are currently preparing to take the board certification examination in April 2016.
Bennett says the AADSM’s one-day Essentials of Dental Sleep Medicine Course is designed to introduce participants to OSA and how to screen for and treat it. Three times a year, the academy also offers a full-day practical course that provides a step-by-step guide to integrating dental sleep medicine into a practice. “We teach them how to take a protruded bite relationship, how to do an airway evaluation, how to take a good sleep history. By the time they leave, I want them to feel confident in the dental side of it. Then they have to make a few [oral appliances] to figure out where they’re making mistakes and begin to understand how the patient is feeling. Then after you’ve made a couple, you start to see some side effects, and you have to learn how to manage them.”
Incorporating Sleep Medicine into a Dental Practice
Bennett notes that in addition to the education, the only piece of equipment that dentists must acquire to start making oral appliances is a protrusive measuring device. The George Gauge made by Great Lakes Orthodontics is most commonly used. “It’s a device for measuring how far the jaw moves forward and where you want to put the jaw to be able to open the airway,” Bennett says. The radiographic and impression-taking materials that are required are already a part of any general dentistry practice, she says.
Bennett and other dental sleep medicine practitioners assert that 3D cone-beam computed tomography (CBCT) scans are not required to screen and treat patients for OSA. However, several imaging companies are currently seeking FDA clearance for using their machines for this purpose, and some dentists who are currently working with the technology express enthusiasm for what it can offer.
One such practitioner is Tarun Agarwal, DDS, a general dentist based in Raleigh, North Carolina. At the time of publication, he is beta-testing a product from Sirona called Si-CAT Air (www.sirona.com), which is designed for use with Sirona’s Orthophos SL and Galileos CBCT device. “You scan the patient and when you capture the airway space, you can segment out the airway and show your patient the amount of opening they have. It’s a great conversation starter because most people don’t walk in understanding or knowing that they have sleep apnea,” he says. If the airway appears to be collapsed, “we recommend that they have a sleep test done and get an official diagnosis.”
Agarwal adds that he is currently using Orthophos SL to screen most of his new patients. “It’s a quantum leap forward from a panorex. A panorex doesn’t show you anything about the airway.”
Clinicians who are incorporating sleep medicine into their practices state that it benefits both patients and clinicians.
“For patients, the benefit is the ability to be screened,” says Radz. Primary medical care providers still do not routinely screen, assess, or refer patients to sleep specialists.16 But dentists can serve as another way to catch sleep disorders, Radz notes. “Sleep apnea is kind of like high blood pressure. You often don’t know you have it until you’ve been tested.”
Radz says a corresponding benefit for dentists is that it enables them to provide a wider scope of care and be a more complete health care provider. “From a business standpoint, it’s another revenue stream, just as if you were bringing orthodontics into your practice or were starting to do sedation or any other area of dentistry.”
“I’m very pro sleep dentistry,” says Roger Levin, founder of Levin Group, Inc., the Baltimore-based dental practice management and marketing consulting firm. “According to the Levin Group Data Center, 75% of dental practices have declined in production over the last 6 years.” Levin says, “Any service that is productive, profitable, and beneficial to a patient and can be added with education to a practice is a good idea.”
Taking the Leap
If practices are going to get involved with dental sleep medicine, Levin advises, “They should not dip their toe in the water. They should market the service, and communicate its availability to all patients. They should develop quite a number of patients who are able to take advantage of the service. I find that too many practices go out of their way to master or learn a new area, and then don’t really ever develop it.”
Larry Twersky, CEO of 1-800-SNORING, points out another pitfall that should be considered by dentists who are considering an expansion into the dental sleep medicine field. “There’s a whole group of dentists who have tried to make money through sleep apnea and failed,” he says. “They tried it once or twice and lost the money because they didn’t know how to work with medical billings. Let’s face it: it’s difficult. The way to get paid for dental insurance is you take an FMX and you’re done. You either have something in the hard tissue or you don’t, but anything relating to the soft tissue requires a lot more documentation.” In the world of medical billing, the need for documentation increases still further.
Because of the added complexity, Twersky and other authorities recommend outsourcing the billing for treating OSA patients. “A lot of companies will want to sell you a billing program, but because the documentation is so overwhelming, it’s just better to find a reputable billing agency. You have to actually fight the insurance company. It requires about six ‘no’s’ before you get a ‘yes.’”
Twersky also warns that dentists entering the field of dental sleep medicine should be aware of the need for interdisciplinary coordination. “It’s the first time in the dental industry that the dentist is not the quarterback. The dentist is part of the team, and the quarterback is the MD.” The need for a team approach may require an adjustment in thinking. Nonetheless, those who adjust can significantly expand their revenue, Twersky believes.
Future Considerations
If Jeffrey S. Rouse, DDS, an expert in “sleep prosthodontics” who practices in San Antonio, Texas, is correct, there’s also a lot more work to be done relating to airway disorders beyond those manifesting during sleep. “Sleep is just one part of it,” Rouse says. “Airway problems are progressive. It’s an airway system, and problems are magnified when the person is sleeping. But all day long you have to manage the airway.” Rouse argues that dentists can and should spot intraoral signs of airway issues at their inception, rather than when they have developed into disease states.
“We focus on apnea because it’s easy to measure,” he says, “but our scope is really too limited.” It’s not just middle-aged men who are affected; children are being damaged quite dramatically by airway problems,17 he contends. Young, fit females are vulnerable to Upper Airway Resistance Syndrome.18 “The true number of people who are impacted by airway and sleep issues is staggering.”
References
1. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014.
2. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827.
3. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. JAMA. 2000;283(14):1829-1836.
4. Beninati W, Harris CD, Herold DL, Shepard JW Jr. The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74(10):955-958.
5. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1(8225):862-865.
6. Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev. 2006;(3):CD001106.
7. Somiah M, Taxin Z, Keating J, et al. Sleep quality, short-term and long-term CPAP adherence. J Clin Sleep Med. 2012;8(5):489-500.
8. Tokunaga T, Nimomiya T, Kato Y, et al. Long-term compliance with nasal continuous positive airway pressure therapy for sleep apnea syndrome in an otorhinolaryngological office. Eur Arch Otorhinolaryngol.2013;270(8):2267-2273. doi: 10.1007/s00405-013-2483-3.
9. Demko BG. Incorporating dental sleep medicine into a practice: avoiding the “7 deadly sins.” Compend Contin Educ Dent. 2014;35(9):640,642.
10. Itzhaki S, Dorchin H, Clark G, et al. The effects of 1-year treatment with a herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest. 2007; 131(3):740-749.
11. Scherr SC, Dort LC, Almeida FR, et al. Definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring. Journal of Dental Sleep Medicine. 2014;1(1):51.
12. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. Journal of Dental Sleep Medicine. 2015;2(3):71-125. Available from: Clinical Practice Guideline for Oral Appliance Therapy. American Academy of Dental Sleep Medicine website. www.aadsm.org/oatguideline.aspx. Accessed December 22, 2015.
13. Scherr, SC. Oral Appliance Therapy for the Future. Sleep Review. 2014;15(1):12-16.
14. Fenton ME, Stewart SA, Skomro R, et al. Utility of STOP-Bang in the prediction of obstructive sleep apnea in primary care. Chest. 2015;148(4_Meeting Abstracts):1033A. doi:10.1378/chest.2278516. 15. About Accreditation. American Academy of Dental Sleep Medicine website. www.aadsm.org/Accreditation.aspx. Accessed December 22, 2015.
16. Miller JN, Berger AM. Screening and assessment for obstructive sleep apnea in primary care. Sleep Med Rev. 2015;29:41-51. doi: 10.1016/j.smrv.2015.09.005. [Epub ahead of print].
17. Rouse JS. Sleep prosthodontics: a new vision for dentistry. Inside Dentistry. 2013:9(7):60-76.
18. Gold AR, Dipalo F, Gold MS, O'Hearn D. The symptoms and signs of upper airway resistance syndrome. Chest. 2003;123;87-95.
CE COURSES
The Bruxism Triad
Jeffrey S. Rouse, DDS
dentalaegis.com/go/id1134
Obstructive Sleep Apnea and the Role of Dental Hygienists
Elizabeth Collins Kornegay, RDH, BSDH; Jennifer L. Brame, RDH, MS
dentalaegis.com/go/id1126
Obstructive Sleep Apnea in Association with Periodontitis: A Case-Control Study
Nuha Ejaz Ahmad, BSDH, MSDH; Anne E. Sanders, PhD; Rose Sheats, DMD, MPH; Jennifer L. Brame, MSDH; Greg K. Essick, DDS, PhD
dentalaegis.com/go/id1128
Sleep Prosthodontics: Analyzing Myofascial Pain
Jeffrey S. Rouse, DDS
dentalaegis.com/go/id1129
Sleep Prosthodontics: How It Can Help Pediatric Patients
Jeffrey S. Rouse, DDS
dentalaegis.com/go/id1130
Sleep Prosthodontics: A New Vision for Dentistry
Jeffrey S. Rouse, DDS
dentalaegis.com/go/id1131
LIVE EVENTS
Introduction to the Practice of Sleep Medicine
Tufts University School of Dental Medicine
Boston, Massachusetts
March 16, 2016 | 9 AM-5 PM
To register: dentalaegis.com/go/id1132
Management of Obstructive Sleep Apnea with Mandibular Advancement Devices
Tufts University School of Dental Medicine
Boston, Massachusetts
June 25, 2016 | 9 AM-5 PM
To register: dentalaegis.com/go/id1133
