Sleep Medicine for Dentists

An Evidence-Based Overview, Second Edition

Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith

• Publisher: Quintessence Publishing Co, Inc
• Year: 2020
• ISBN:
  9781647240097
• Edition: 2
• Topic: Medicina
• Subtopic: Odontología

Dentists are often the first medical practitioners to encounter patient reports or clinical evidence of disorders such as sleep apnea, sleep bruxism, and sleep-disrupting orofacial pain, providing them a unique opportunity to prevent the development or persistence of conditions that strongly impact their patients' lives. Since the first publication of this seminal book, significant advances have been made in the field of sleep medicine, and this updated edition gathers all of this new evidence-based knowledge and presents it in focused, concise chapters. Leading experts in medicine and dentistry explain the neurobiologic mechanisms of sleep and how they can be affected by breathing disorders, bruxism, and pain, along the way guiding dental practitioners in performing their specific responsibilities for screening, treating, and often referring patients as part of a multidisciplinary team of physicians. An emphasis is placed on research findings regarding newly emerging cognitive behavioral approaches to treatment that mitigate some of the risks associated with pharmacologic and oral appliance therapies. Readers will find this book both fascinating and clinically important as they strive to provide the best possible treatment to patients with these complex and often life-threatening disorders.

CHAPTER 5

Overview of Guidelines/ Protocols for SDB

Galit Almoznino
Rafael Benoliel
Frank Lobbezoo
Luc Gauthier

This chapter reviews the diagnostic and therapeutic protocols that have been published in different countries for dentists regarding the screening and management of adults affected by SDB.1–3 chapters 3 and 4 overview the role of the dental sleep medicine team in the screening, diagnosis, and management of sleep disorders. The present chapter reviews the protocols in the management of OSA and snoring—covering the indications and proper use of OAT to treat various forms of SDB. Most of these protocols are based on systematic literature reviews, meta-analyses, and expert panel consensus or agreement (diplomatic or legal).1–5 In order to provide a customized medical service, these protocols take into account the differences between different settings—both local and national.1

Consensus guidelines have been published by the American Academy of Sleep Medicine (AASM),6 American Academy of Dental Sleep Medicine (AADSM),7 American Dental Association (ADA),8 and other dental sleep medicine professionals in Canada,3 Australia,4 India,9 Italy,1 Germany,2 and Britain.5 Some of these protocols are summarized in the present chapter. Note that such guidelines were not developed for pediatric cases (see chapter 14). Furthermore, the authors do not intend to summarize the available guidelines to edict legal regulatory rules; the main objective of the authors is to promote the best DSM practices throughout the world.

The Role of Dentists in Screening and Managing SDB and OSA

All consensus papers highlight the significant role that the dentist plays in screening and managing SDB.1–5,8 An algorithm describing the role of the dentist in the management of patients with snoring complaints and OSA is presented in Fig 5-1.

FIG 5-1 Algorithm for the role of the dentist in the management of patients with snoring and OSA.1–4,7,8,10–13,16

It is generally accepted that the dentist’s role is to screen for potential SDB3,5 but not to diagnose SDB.3,5 Management of SDB is handled by a team of health practitioners (see chapter 4) with respective expertise; only a physician qualified in sleep medicine can act as the “chief conductor” of the medical team.

Because patients with SDB may present to their dentist before their medical doctor, dentists have the potential to recognize patients with SDB who might not otherwise be diagnosed.5 A synthesis of consensus statement recommendations for SDB screening by dentists are presented in Figs 5-2 and 5-3.

FIG 5-2 Recommendations for screening of SDB, according to consensus statements in different countries.1–7,16 (Adapted from Almoznino16 et al with permission.)

FIG 5-3 Clinical examinations as part of the diagnostic work-up for screening SDB, according to consensus statements in different countries.1–7,16 TMJ, temporomandibular joint; GERD, gastroesophageal reflux disease.

Comprehensive medical and dental histories as well as physical examination should be performed to assess sleep history and symptoms related to SDB, sleep routine, comorbid medical conditions, psychiatric illnesses, medications, drug and alcohol abuse, and poor lifestyle10 (see Fig 5-2). This is described in more detail in chapter 11. Complex medical conditions often may result from co-existing sleep disorders, with a higher prevalence of cardiacdisease, hypertension, lung disease, diabetes, peptic ulcers and gastroesophageal reflux, arthritis, asthma, and neurologic and menstrual problems.5,11,12 Particular medical issues requiring careful consideration include medical conditions that are associated with OSA, are exacerbated by OSA, or limit the use of an OA.5

Validated sleep measurements should be employed under medical supervision5 (see chapter 11), be kept on medical and dental records, and be reviewed pretreatment and at various time points during treatment.3 Reports from partners or caregivers regarding sleep habits, excessive daytime sleepiness, restless sleep, periodic limb movements, tooth-grinding sounds, temporomandibular joint (TMJ) sounds, snoring, witnessed apneas, substance use (eg, alcohol, tobacco, caffeine), and other habits are important to collect5,11 (see Fig 5-2). In addition, extra- and intraoral examinations (see Fig 5-3) should assess for risk factors of EDS, OSA (obesity and specific craniofacial morphologies), SB,12,13 and TMDs.3 Intraoral examination should assess oral, dental, and periodontal health status; malocclusions; oropharyngeal structures; as well as abnormal tooth wear, tongue indentations, and ridge-like bite marks inside the cheek3,11 (see Fig 5-3).

Dental casts and models of baseline occlusion are recommended to monitor for potential changes over time.3 Oral photographs can also be added to the patient records to document the baseline.

Although not routinely indicated, diagnostic imaging has been demonstrated to be useful in diagnostic and morphometric analysis of hard and soft tissue structures prior to OAT4 (see chapter 12 for detailed description of techniques). These include baseline panoramic and cephalometric radiography, CBCT, and CT; other advanced imaging may be ordered in select cases for further evaluation of certain structures, such as the TMJs.4

Multidisciplinary Management of SDB and OSA

Dentists should refer patients suspected of suffering from sleep disorders to a sleep medicine physician for further evaluation and establishment of the SDB diagnosis, severity and site(s) of obstruction, and/or other sleep disorder diagnoses.3,4,8

SDB is managed by a multidisciplinary team (see chapter 4) that includes sleep medicine specialists from many different medical specialties, including family and internal medicine, pediatric medicine, otorhinolaryngology, pulmonology, neurology, psychiatry, anesthesiology, gastroenterology/bariatric surgery, respiratory therapy, diet therapy, psychology, physical therapy, and nursing trained in sleep medicine.4,10,12,14

In countries/regions where a sleep medicine physician is unavailable, the dentist should refer the patient to a family physician for direct collaboration and potential referral to an appropriate medical specialist.3

The dentist who received training in sleep medicine will manage the treatment within his or her expertise; however, other dental professionals in various specialties may also have a significant role in the multidisciplinary team.4 For example, patients suffering from orofacial pain (ie, TMDs and headaches) should be managed in collaboration with orofacial pain specialists,3,10 physical therapists, and psychologists. Oral and maxillofacial surgeons can perform maxillomandibular surgery to treat OSA. Orthodontic treatment following surgery may also be required to ensure stable repositioning as well as to prevent OSA exacerbation ...

Table of contents

• Cover
• Half Title
• Copyright Page
• Title Page
• Contents
• Foreword by David Gozal
• Preface
• In Memoriam
• Contributors
• Abbreviations
• Section I: Introduction to Dental Sleep Medicine
• Section II: Sleep Breathing Disorders
• Section III: Sleep Bruxism: From Oral Behavior to Disorder
• Section IV: Sleep and Orofacial Pain
• Index
• Backcover