By Dr. Jonathan A. Parker
Dr. Jonathan A. Parker, a charter member of the Academy of Dental Sleep Medicine who has treated patients in a practice restricted to management of snoring and OSA for more than 10 years, believes dentists can and should treat and diagnose these sleep disorders. He also said that those who do so would find the experience very rewarding.
In the following interview with Dental Products Report, Dr. Parker explains the role of dentists, background on the topic, how to diagnose and treat the sleep disorders, how to communicate with patients' physicians, and different types of appliances used to treat sleep disorders.
PARKER: Absolutely. Dentists can play a very important role in identifying patients with these sleep disorders and providing effective treatment. If you have not been involved in this area of dentistry in the past, it will become one of the most gratifying services that you can provide in your practice. You can change people's lives by improving their health, their sleep, and the sleep of others nearby.
PARKER: There are numerous diagnostic categories in sleep medicine including Insomnia, narcolepsy, periodic limb movement disorders, and REM behavior disorders, to name just a few. Dentists can play an important role in identifying and treating snoring and obstructive sleep apnea (OSA), which are the most common sleep disorders, and parasomnias such as sleep bruxism.
PARKER: Approximately 40% of adults over 40 years of age snore. This amounts to about 90 million Americans. Nine percent of men and 4% of women have the signs of obstructive sleep apnea on testing. Therefore, 40% of adults in our dental practice are snorers, and at least 10% to 20% of those adults have sleep apnea. OSA is as prevalent as diabetes or asthma.
PARKER: Snoring is the harsh sound that you hear when a snorer inhales during sleep. The noise occurs when the soft palate and uvula vibrate against the back of the throat or the base of the tongue.
Sleep apnea is a condition in which the tongue and soft palate relax and close off the airway so that air cannot flow into the lungs. This airway blockage can reduce the amount of oxygen reaching the brain and the body. When that happens, the brain alerts the muscles in the airway to tighten up and unblock the air passage. As this occurs a loud gasp or snort is heard and then breathing (and many times snoring) begins again. This process of blocking and unblocking the airway causes significant disruption in sleep.
PARKER: Common symptoms of OSA are:
People who suffer from OSA frequently complain of daytime sleepiness that can impair their ability to concentrate at work or at home and may cause difficulty staying awake while watching TV, reading, or in meetings. Snoring and sleep apnea can have a significant impact on a marriage or relationship, because the loud snoring can affect others sleeping nearby. It, addition, people with OSA have a higher risk of high blood pressure, heart attack, and stroke. They also have a higher rate of motor vehicle accidents.
PARKER: I would suggest that the dentist ask new patients and patients who
come in for periodic hygiene visits some screening questions, such as "Have
you been told by others, or are you aware that you have a tendency for snoring?
When you awake in the morning, do you feel refreshed?"
Those two questions can be used as a first step to identify patients with
snoring and sleep apnea problems. If you receive a positive response to these
questions, then you can proceed with additional questions and evaluation to
diagnose the problem.
PARKER: Yes. Snoring and OSA are medical health conditions that are usually categorized as respiratory disorders of sleep. These medical conditions are best managed by a physician who specializes in sleep disorders. I would encourage dentists to develop a relationship with the sleep disorders center in their community. The dentist and sleep medicine physician can develop an appropriate protocol for coordinating diagnosis and treatment of these patients. You will be providing a tremendous service by coordinating their care in this manner.
PARKER: As in any aspect of the practice of dentistry, or medicine for that matter, the key to successful treatment is an accurate diagnosis. A good history must be accompanied by appropriate and thorough examination and testing in order to determine that diagnosis. There are also medical-legal concerns regarding a dentist providing care as the primary provider for a patient with snoring and OSA. Therefore, developing a protocol with the sleep medicine physician in your community will allow the dentist to provide treatment according to the standard of care in your area.
PARKER: Yes, there are a number of simpler options available. Since obesity is directly correlated with snoring and OSA, maintaining appropriate body weight is very important. Weight loss may be the most effective treatment for some snorers. Sleep position also can have a significant impact on snoring. About 60% of snorers will only snore while sleeping on their backs, therefore use of a cushion to prevent supine sleep can be very effective for patients with positional snoring.
Nasal obstruction is not usually the primary cause of snoring, but it can aggravate the problem. Nasal sprays may be helpful, but should be limited to short-term use (60 days) and nasal strips such as BreatheRight™ may be beneficial for some patients. Avoidance of alcohol and sedative hypnotics within three hours of bedlime is very important to managing snoring and OSA. These simpler options will also increase the probability of success when used in conjunction with oral appliance therapy.
PARKER: The most common medical treatment for moderate to severe OSA is the Continuous Positive Airway Pressure (CPAP) device. This device has a small air blower connected by a flexible hose to a cushioned plastic mask that covers the nose. The blower forces air into the nose and throat to keep the air passage open during sleep. Research studies have shown that this treatment is effective in 98% of the patients with OSA. However, compliance with nasal CPAP is approximately 60%; so about 40% of the patients are unable to tolerate the device.
Surgery is another alternative for managing snoring and OSA. The most common
surgical procedure is a uvulopalato-pharyngoplasty (UPPP) that is done as
an in-patient procedure In the hospital. This procedure removes all of the
uvula and about one-third of the soft palate. Another procedure similar to
the UPPP uses a laser to remove a portion of the soft palate and uvula. This
treatment is called laser-assisted uvuIopalatoplasty (LAUP). The treatment
is done in the physician's office by a qualified surgeon. It is usually completed
in phases, which may require separate surgical procedures. These two palatal
surgeries have been shown to be 40% to 50% successful in treating OSA and
have been more effective in cases of primary snoring. The recovery time for
palatal surgery is 10-14 days and the procedure is reported to be quite painful.
Somnoplasty (radio frequency surgery) is a minor surgical procedure completed in the physician's office using local anesthesia and a customized electrode that delivers radio- frequency energy to the soft palate. This treatment reduces snoring by creating scarring or stiffening the tissues, which decreases vibration of the soft palate. It has not been shown to be effective for OSA.
Telegnathic (jaw) surgery may also be indicated for patients with severe OSA that may be life threatening. These osteotomy procedures will generally advance the maxilla and mandible approximately I0 to 15 millimeters to open the airway and significantly improve the apnea condition. Research studies show an 80% to 90% treatment success rate for severe OSA.
PARKER: The two main classifications of appliances are the mandibular advancement devices and the tongue retaining devices. The mandibular advancement device holds the lower jaw slightly forward and open, which advances and stabilizes the mandible, tongue, and hyoid bone to increase airflow and reduce snoring and apnea. Research studies have shown that the airway opens significantly in a lateral direction and slightly in an anterior posterior direction to restore proper breathing. The tongue retaining device actively holds the tongue forward to open the airway and improve airflow.
PARKER: Yes. It is important for the dentist to become educated about the various features of the oral appliances that are available. There are about 45 oral appliances on the market at the present time. The key characteristics that the dentist should evaluate are:
The appliances can be constructed by a dental laboratory or at chairside
using a stock "boil and bite" type of device. The laboratory-fabricated
appliances are more durable, more retentive, and have a greater range of adjustability.
I believe that the dentist should have the knowledge and skills to use at
least three or four different appliances in order to meet the varied needs
of individual patients. It is appropriate to use one particular appliance
for the majority of patients, but issues such as bruxism, sensitive gag reflex,
steep mandibular plane angle, TMD symptoms, missing teeth, the need for a
temporary device, etc., requires that the dentist understand the limitations
and benefits of a number of appliances.
Currently in my practice, I use the Adjustable PM Positioner from Dental Services Group for about 70% of my patients because of its durability, effectiveness, comfort, and ease of insertion and removal.
However, I work with five other appliances from which I can select an appropriate
device for the 30% of my patients who have specific needs, Having multiple
appliances available in your armamentarium will increase treatment success
and patient satisfaction. I would encourage you to try a few of the appliances
to determine what works best for you and your patients.
PARKER: Oral appliance therapy is approximately 85% to 90% effective in treating snoring. Research studies on OSA have shown that for mild apnea (less than 20 events per hour), the mandibular advancement devices reduce the apnea level to normal for 76% of the patients. In patients who have moderate OSA (20 to 40 events per hour), the mandibular advancement appliances are 61% successful. The patients with severe OSA (greater than 40 events per hour) have a 40% to 50% success rate.
PARKER: The minor side effects include excessive salivation or in some cases
the patient will experience a dry mouth. The patients may have discomfort
of the teeth or jaw that is not significant enough to cause them to quit using
the device. They will also experience temporary changes in their occlusion
especially in the morning upon waking.
The more significant side effects are jaw pain, occlusal changes, and TMJ
noise. Jaw pain may occur in approximately 10% to 20% of the patients; however,
a small percentage of those patients will have persistent pain with using
the device, Permanent occlusal changes will occur in approximately 15% to
20% of the patients. In many cases, if the patient were to discontinue the
device, the occlusion would return to normal. Increased TMJ noise or noise
that is caused by the appliance is relatively infrequent.
PARKER: The Academy of Dental Sleep Medicine is the organization that can provide the necessary support and guidance to dentists who are interested in providing care for patients with snoring and OSA. You can contact the Academy of Dental Sleep Medicine at 724-935-0836 or visit the organization's Web site at http://www.dentalsleepmed.org. In addition, many of the state, regional, and national dental meetings are beginning to include lectures on diagnosis and treatment of OSA.
There are millions of people suffering from the effects of OSA and their sleep partners are suffering from the noise of their snoring. Dentists can play an important role in identifying these patients and can provide important treatment for managing this significant health problem. It is a wonderful experience as a healthcare provider to have patients tell you that you have changed their lives. I would encourage you to explore this new area in dentistry.
Reprinted from Dental Products Report with permission of MEDEC Dental Communications,
2002, A Medical Economics Company
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Snoring & Sleep Apnea Dental Treatment Center
7225 Ohms Lane, Suite 180
Edina, MN 55439
952-345-0290
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