The Role of Dentistry Position paper by Mitchell Marder, DDS
Sleep disordered breathing (SDB) is a condition affecting 10% of children, 44% of adult males, and 28% of adult females. In fact, there is research that connects ADHD, developmental delay, poor concentration, bed-wetting, night terrors, obesity, and earaches in children with sleep disordered breathing.
Accompanying SDB, we often find hypertension (35%), obesity (90% males, 50% females), diabetes (50%), heart failure (50%), atrial fibrillation (50%), heart attack (50%), stroke (67%), asthma (15%), and gastro-esophageal reflux disease (15%). Sleep disordered breathing is also associated with a seven fold increase in the incidence of motor vehicle accidents, linked to an increase in work and home accidents, and implicated in failed personal relationships due to snoring.
During sleep, the tongue can fall back into the throat and obstruct the airway. Snoring comes from vibration of the uvula as it is sucked back into the throat, partial collapse of the oral pharynx. It may occur alone or as a presenting feature of obstructive sleep apnea (see below). As breathing is interrupted, blood pressure rises. As the throat obstruction worsens, apnea events (waking up gasping for air) become more frequent. The apneic person wakes tired and often will fall asleep during daytime hours, such as, tragically, behind the wheel while driving.
It is the dentist’s role to ask about sleep patterns, presence of snoring, to examine uvular edema (swelling), tonsilar size, tongue size, and narrow palate. The dentist should check for narrow palates and retruded lower jaws, offering orthopedic palate expansion and mandibular (lower jaw) advancement, especially in children. The dentist should feel comfortable in referring to a sleep specialist or for a sleep test. At home SDB screening tests are available and relatively inexpensive. But currently, treatment is only reimbursable by the insurance industry if SDB is measured in a sleep lab.
It is incumbent upon dentists to take on the responsibility of screening for SBD and either offer services of sleep testing and oral appliance therapy or refer to specialists in sleep dentistry, otolaryngology and sleep medicine.
OBSTRUCTIVE SLEEP APNEA
OSA occurs when air cannot flow through a person’s nose or mouth. The number of involuntary breathing pauses, or “apneic events” may be as high as 60 per hour. If the tongue and jaw muscles relax enough, the airway is blocked, oxygen drops, and the apneic event of waking occurs. The sufferer is not aware of waking, but sleep is severely disrupted. Snoring and choking between events is common, but not all snorers are apneics.
Apneics are tired during the day and may fall asleep at work, while stopped at a traffic light, while reading, or other times of day. More serious consequences associated with OSA include depression, hypertension, heart conditions, sexual problems, weight gain, memory lapses, intellectual deterioration and morning headaches.
Overnight sleep studies is the gold standard for diagnosis of OSA, but certain home screening tests are less cumbersome and can determine the need for a full sleep study (polysomnography).
In addition to weight loss, sleep position change, and improvements in sleep habits, the most common treatments for OSA are:
•Nasal CPAP (continuous positive airway pressure) which is a plugged-in unit that delivers a positive flow of air through a nose mask to keep the upper airway open, precluding apneic events.
•Oral appliance therapy which is similar to a mouth guard, a custom-made appliance to hold the lower jaw forward which keeps open the airway and permits normal breathing during sleep. This minimizes snoring as well as apneic events. This appliance is recommended for moderate apnea, defined as less than 30 events an hour.
•Medications, removal of tonsils, operations to remove parts of the uvula and soft palate