The Clinician's Handbook for Dental Sleep Medicine

Ken Berley, Steve Carstensen

• Publisher: Quintessence Publishing Co, Inc
• Year: 2019
• ISBN:
  9780867158571
• Topic: Medicine
• Subtopic: Dentistry

It has been estimated that 20 million Americans suffer from moderate to severe OSA, and at least one patient in five has mild OSA. The primary treatment prescribed by sleep physicians is CPAP, but patient compliance with this therapy is unacceptably low, between 25% and 50%. There is a significant opportunity for dentists to provide a viable alternative therapy—oral appliance therapy (OAT). OAT results in much better adherence to therapy than CPAP, and while OAT is not as efficacious as CPAP, this increased compliance results in comparable therapeutic results. Currently, a board-certified sleep physician is the only medical professional qualified to diagnose OSA and other sleep-related breathing disorders (SRBDs), so dentists must coordinate with a sleep physician to provide OAT. This book is the how-to guide, a gateway to a successful dental sleep medicine practice. Written by two experts in the field, it clearly delineates the dentist's role in the treatment of SRBDs and gives practical advice for how to incorporate dental sleep medicine into an existing dental practice, not to mention how to work with sleep physicians to best support patient care. In addition to step-by-step instructions for examination, appliance selection, and follow-up care, complications of OAT, legal issues, and medical insurance and Medicare considerations are included to fully prepare the dentist for the journey into dental sleep medicine.

Chapter 01

Clinical Guide for the Practice of Dental Sleep Medicine

The woods are lovely, dark and deep.
But I have promises to keep, and miles to go before I sleep.

ROBERT FROST

From the dawn of modern civilization, man has cherished and worshiped sleep. Sleep was deified by the Greeks and the Romans, resulting in their gods of sleep, Hypnos and Somnus. Yet today, a good night’s sleep has never been harder to achieve. Sadly, many of the reasons people are having trouble sleeping are self-inflicted. Today we are hyperconnected with a growing array of computer-driven screens and glowing devices. We now have the ability to work anywhere on the face of the planet and have constant contact with anyone in the world. The health-conscious person striving for a good night’s sleep must be very disciplined in light of this sensory onslaught.

In addition to the societal and entertainment choices that rob us of sleep, our ability to sleep is directly affected by certain physiologic characteristics or anatomical deficiencies. These physical characteristics that alter our ability to sleep can give rise to insomnia, an altered arousal threshold, asphyxia, and sleep fragmentation that can result in excessive daytime sleepiness (EDS) and contribute to a host of comorbid diseases. Fortunately, with the help of trained professionals, our sleep can be improved. By modifying or enlarging a patient’s upper airway with the assistance of either continuous positive airway pressure (CPAP), surgery, orthodontics, or a mandibular advancement device (MAD), nocturnal oxygenation may be increased, thereby improving the quality and quantity of sleep. Dental sleep medicine (DSM) was founded on the principle that the movable mandible can be supported during sleep to maintain an open airway. This simple act of holding the mandible in a stable or slightly protruded position during sleep may be adequate to prevent or mitigate the physiologic consequences of airway obstruction and the resultant nocturnal hypoxemia. There is an ever-increasing number of MADs that are cleared by the US Food and Drug Administration (FDA) to treat sleep-related breathing disorders (SRBDs), including snoring and obstructive sleep apnea (OSA). This fact has allowed properly trained dentists to become an integral partner in the treatment of SRBDs.

THE RISE OF DENTAL SLEEP MEDICINE

This is an exciting time to be a dentist. The field of DSM is exploding. This is primarily due to the fact that the majority of individuals with sleep disorders do not present to their physicians for treatment of their sleep issues.¹ These patients typically seek medical care for treatment of the comorbid diseases that are directly associated with sleep-disordered breathing, in particular hypertension, fatigue, stroke, cardiovascular disease, and diabetes. Sadly, most physicians do not screen for SRBDs, and the precipitating factors contributing to the patient’s chief complaint frequently go undiagnosed.² However, many of these patients who suffer from sleep issues will present for routine dental examinations and care. A dentist who is properly trained to recognize the signs and symptoms of sleep-disordered breathing can potentially provide life-saving referrals and MAD therapy for their sleep-deprived patients. Fortunately, patients with sleep-disordered breathing exhibit identifiable intraoral signs and symptoms as well as physical and social symptoms. With the appropriate training, dentists are well situated to screen and treat many of these patients.

The screening and treatment of our dental patients who have OSA has led to the birth of DSM. While still in its infancy, DSM is the fastest-growing discipline in dentistry. Screening and treating patients with SRBDs can greatly improve the health of these patients and potentially add a significant source of income to your dental practice.

ADA policy statement on SRBDs

In 2017, the American Dental Association (ADA) voted to approve a policy statement on dentistry’s role in the treatment of SRBDs.³ This policy places SRBDs firmly within the scope of practice of every dentist. While dentists are not obligated to provide treatment for SRBDs, dentists are now required to screen all patients for SRBDs and document the results in each patient record. When the screening is positive, the patient must be informed of the possibility of sleep-disordered breathing and referred to a sleep physician for appropriate diagnosis and therapy.

FIG 1-1 Patient during a PSG.

TERMINOLOGY

Sleep-related breathing disorder

A sleep-related breathing disorder is a chronic disease caused by repeated upper airway collapse during sleep resulting in recurrent nocturnal asphyxia, fragmented sleep, major fluctuations in blood pressure, and increased sympathetic nervous system activity.⁴ Readers should be aware that while OSA is also generally referred to as SRBD, in reality SRBD is a much broader term that includes a spectrum of breathing anomalies ranging from chronic or habitual snoring (resulting in airflow limitations) to upper airway resistance syndrome (UARS) to frank OSA, central and complex apnea, or in some cases, Cheyne-Stokes respiration and obesity hypoventilation syndrome.

Polysomnography

A polysomnogram (PSG), also called a sleep study, is a test used to diagnose sleep disorders. A PSG provides a continuous recording of specific physiologic markers and variables over a full night of sleep that helps to identify and diagnose various sleep disorders (Fig 1-1). Typically, a PSG records changes in brainwaves (via electroencephalogram [EEG]), eye movements (via electrooculogram [EOG]), muscle tone (via electromyogram [EMG]), respiration (via nasal flow sensor and effort belts around the chest), heart rate (via electrocardiogram [ECG]), and leg movements (via EMG).

Obstructive sleep apnea

Obstructive sleep apnea is the most common type of apnea and is characterized by repetitive episodes of partial obstruction or complete obstruction of the patient’s airway during sleep, despite the effort to breathe, and is usually associated with a reduction in blood oxygen saturation (SaO₂). Repetitive reduction of airflow is termed hypopnea, and complete cessation of airflow is termed apnea. These episodes of decreased breathing, called apneas (literally meaning “without breath”), typically last 20 to 40 seconds.⁵ The level of OSA is described by the Apnea-Hypopnea Index (AHI), a count of respiratory events divided by the time of the testing.

Common symptoms of OSA include the following⁶:

●Unexplained daytime sleepiness, restless sleep, and loud snoring (with periods of silence followed by gasps); the severity of EDS does not correlate closely with AHI

●Attention deficit and/or hyperactivity in children

●Trouble concentrating; mood changes such as irritability, anxiety, and treatment-resistant depression and forgetfulness

●Temporomandibular disorder symptoms, sleep bruxism

●Decreased sex drive, sexual dysfunction, and heavy night sweats

Some OSA patients may experience additional symptoms⁷:

●Restless leg syndrome/periodic limb movements

●Restless or fragmented sleep and lack of dreams

●Increased heart rate and/or blood pressure (systemic hypertension), ischemic heart disease, congestive heart failure

●Decline in performance at work

●Dry mouth/throat sensations upon awakening

●Fatigue

●Gastroesophageal reflux disease (GERD)

●Impaired cognition (memory and concentration)

●Insomnia and parasomnias (confusional arousals and sleep-related eating disorders)

●Morning headaches

●Nocturia

●Witnessed apnea

●Nonrestorative or unrefreshing sleep

●Repeated awakenings with gasps or choking

Other medical problems common with patients with OSA include stroke or other ischemic cerebrovascular disease and diabetes and/or insulin resistance. They may experience unexplained weight gain. Drowsiness in the daytime can result in increased industrial and automobile accidents. Some research is linking OSA to cognitive decline such as dementia.⁷

HOW BIG IS THE PROBLEM?

In spite of the severe societal and health consequences of SRBDs, a surprisingly small number of studies have been conducted using PSG to determine the prevalence of OSA in the general population. Most studies performed to date simply extrapolate the data to derive an estimate of SRBD prevalence. It has been estimated that 20 million Americans suffer from moderate to severe OSA and at least one person in five (65 million Americans) has mild OSA. In the late 1980s and early 1990s, three large cohort studies were done in the United States: the Wisconsin Sleep Cohort,⁸ the Sleep Heart Health Study,⁹ and the Penn State Cohort.¹⁰ Based primarily on these three studies, the prevalence of SRBDs was estimated to be between 6.5% and 9% in women and between 17% and 31% in men. However, these prevalence estimates were subsequently revised to 34% in men aged 30 to 70 years and 17% in women aged 30 to 70 years.¹¹ All of these studies are somewhat flawed in that the prevalence of SRBDs was not measured directly by sleep studies but was derived from statistical calculations. Nonetheless, it is conservatively estimated that 52 million Americans have clinically significant OSA.¹²

In 2015, the HypnoLaus Study was published in Lancet and reported a significantly higher incidence of OSA.¹³ In this study, 2,121 citizens of Lausanne, Switzerland, were diagnosed after a full-night PSG (via home sleep apnea testing [HSAT]). Of the participants, 1,024 (48%) were men, and 1,097 (52%) were women. The median age of all participants was 57 years (interquartile range 49 to 68; range 40 to 85), and the mean body mass index (BMI) was 25.6 kg/m².

Figure 1-2 shows the prev...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Preface
• 1 Clinical Guide for the Practice of Dental Sleep Medicine
• 2 An Overview of Sleep & Sleep Disorders
• 3 Dental Sleep Medicine Protocol and Practice
• 4 Integrating Dental Sleep Medicine into Your Practice
• 5 Treatment Decisions and Appliance Selection
• 6 Delivery of a Custom MAD
• 7 Complications of Oral Appliance Therapy
• 8 Evaluating Therapy and Ongoing Care
• 9 The New Reality
• 10 Legal Issues Related to the Practice of Dental Sleep Medicine
• 11 Medical Insurance and Medicare
• 12 Pediatric Airway Problems
• Sleep Medicine Terminology
• Recommended Materials
• Index