Don’t Sleep on a Golden Opportunity
The average human spends almost 30% of his or her life sleeping.1 That means that people with sleep-disordered breathing spend almost 30% of their lives at risk of severe and sometimes fatal consequences that could be prevented with the help of dental and medical professionals. Dental sleep medicine, a service that focuses on the use of oral appliance therapy to treat sleep-disordered breathing, including snoring and obstructive sleep apnea (OSA), can be integrated into almost any general practice.2
Sleep-disordered breathing comprises a variety of sleep-related abnormalities, such as snoring, upper airway resistance syndrome, and OSA.1 Overall, snoring affects approximately 90 million American adults, with 37 million affected on a regular basis.3 While males are more often affected, females can also exhibit snoring, and prevalence increases with age.3 The risk of snoring increases in patients who are overweight, use alcohol, smoke, or have a nasal obstruction.3,4 Snoring is linked primarily to two adverse health effects: daytime dysfunction and heart disease. However, it is also a main symptom of a more severe sleep disorder: OSA, which affects about half of people who snore loudly.3
For the approximately 25 million adults in the Unites States who have OSA, this chronic condition occurs when the muscles relax during sleep, allowing soft tissue to collapse and block the airway. This can cause a pause in breathing that lasts from a few seconds to more than a minute.5
“I think the most important thing to remember is that OSA is an epidemic. In every dental practice, about 20% of patients have undiagnosed and untreated OSA. Dentists see their patients more often and are perfectly positioned to screen and educate them about OSA. It’s the first line of defense,” says Harold A. Smith, DDS, President of the American Academy of Dental Sleep Medicine (AADSM).
According to the AADSM, when pauses in breathing occur during an apnea, oxygen levels are often reduced, which disturbs your sleep and poses additional health risks, such as excessive fatigue, headaches, and memory loss.5 When left untreated, OSA can lead to other health risks, including high blood pressure, stroke, heart disease, diabetes, chronic acid reflux, and erectile dysfunction.5 Sleep-disordered breathing is also associated with a considerable mortality risk.1 In fact, annual US cardiovascular deaths related to OSA total nearly 38,000.6 Despite the severe risks associated with sleep-disordered breathing, a collaboration between medical and dental professionals can prevent these detrimental effects when patients are offered proper diagnosis and treatment. Unfortunately, up to 90% of people with OSA are not diagnosed and therefore do not receive appropriate treatment.6
Diagnosing Sleep-Disordered Breathing
Snoring is typically noticed first by bed partners, family members, or friends who have shared a room with the patient while sleeping, but patients may also notice a feeling of fatigue during the day as a result of snoring.1 Not all snorers have OSA, and not all patients with OSA snore, but because snoring is a main symptom of OSA, it is important to review other related symptoms.
In addition to snoring, other signs of OSA include gasping or choking sounds during sleep.5 OSA is similar to snoring in that it is more common in men, but can also occur in women. Excess body weight, a narrow airway, and a misaligned jaw can all increase the risk of OSA.5 In order to properly diagnose the condition, a physician must complete a full history and examination, which may include an overnight sleep study at a sleep center or a home sleep test.5
Gary Radz, DDS, who maintains a private practice in Denver, Colorado and teaches as an associate clinical professor at the University of Colorado School of Dentistry, notes that all of his patients are screened for OSA, and those at risk are prescribed a home sleep test by a board certified sleep physician. Upon return, the information is downloaded from the home sleep test and sent to the physician for diagnosis. “The doctor then makes the treatment recommendations. If an oral appliance is one of the recommendations, we can then help our patient with this.”
The Role of the Dentist
Although dentists cannot diagnose sleep apnea, they can absolutely take part in screening for sleep disorders—a vital first step to getting patients the help that they need. “Sleep apnea is a very serious and potentially life-threatening disease. Dentists are in a great position to be on the front lines to screen patients to see if they may have sleep apnea,” says Dr. Radz.
According to Sal Rodas, Executive Director of the Foundation for Airway Health and CEO of Sleep Architects, there are many dental comorbidities associated with patients who suffer from sleep disorders, including bruxism, clenching, temporomandibular joint (TMJ) disorders, narrow arches, and abfractions.7 The National Institutes of Health estimates that approximately 50 to 70 million US adults have sleep-related disorders.8
“In addition to patient identification, properly trained dentists may also treat patients with oral appliance therapy,” says Mr. Rodas. “To date, many patients that suffer from sleep disorders have benefited from dental intervention. However, the prevalence of sleep disorders in America and around the world is growing at alarming rates. We desperately need more practitioners to at least identify patients and ideally deliver care.”
There are also technological options available to help screen patients for sleep-disordered breathing, such as cone-beam computed tomography (CBCT). Robert Kaspers, DDS, who maintains a private practice in Northbrook, Illinois, agrees that while a medical history and clinical exam are pertinent, these are only part of the puzzle when screening for sleep apnea. “It is really critical to get a much more accurate assessment, and that’s something the CBCT will give you versus just looking at symptoms.”
In his practice, he often encounters TMJ patients, who were fitted at another practice for an oral appliance to help with teeth grinding, but report needing to take out the appliance in the middle of the night because they believe that it wakes them up. They come to his practice assuming that the appliance was made incorrectly, but Dr. Kaspers uses CBCT, a technology not available at all practices, to examine their airway and identify the real problem. “What they don’t realize is that the appliance was relaxing their musculature and it woke them up because they were having an apnea. This is something that until you have the scan to show patients, they would never know that they are having an airway problem. When you have a CBCT scan that can show how closed off the airway is, it becomes a good deal easier for the patient to see that there is an issue.”
The Occlusion Factor
Sleep-disordered breathing can be caused by skeletal malocclusion, which is a result of the distorted development of proper mandibular and/or maxillary growth during fetal development. The likelihood of this is high because of the developmental complexities of the face. Patients who suffer from skeletal malocclusion may also experience other comorbidities, including breathing obstruction.9
“Indeed, malocclusions have been shown through literature to cause obstruction of the airway, snoring, and sleep apnea,” says Mr. Rodas. “Correction of these malocclusions—mainly that of class II patients—has been shown to increase airway dimension and reduce and/or successfully manage sleep-related disorders.”
A study by Maspero et al showed that the sagittal dimension on the posterior oropharyngeal airway was increased by correcting mandibular restrusion in patients with class II malocclusion.10 The literature also supports early intervention for class II correction, as it can eliminate changes in the upper airway that contribute to predisposing factors leading to OSA, which would decrease the chance of developing OSA as an adult.10
“Issues with occlusion may be a factor in diagnosis and deciding the best treatment for the patient. This is why quality education is important for a dentist. Occlusion, TMJ, and other issues need to be considered when deciding on a treatment solution,” explains Edward Dyer, Senior Regional Sales Director at KaVo Kerr, who also uses a sleep appliance due to his sleep-disordered breathing.
Payam Ataii, DMD, who maintains a private practice in Laguna Hills, California, agrees that malocclusion and sleep-disordered breathing are intrinsically linked. “As an Invisalign faculty member and provider of clear aligner treatments in my practice for over 10 years, crowding, spacing, and common malocclusions are not just from orthodontic relapse. In fact, in some instances, there is a clear, distinct connection to sleep-disordered breathing that is caused by narrow arches and other dentofacial deficiencies that could be addressed by the trained practitioner.”
Treating Sleep-Disordered Breathing
The most common treatment for sleep-disordered breathing is oral appliance therapy, which can be effective in treating both snoring and OSA. An oral appliance is worn while sleeping and maintains a forward positioning of the jaw to keep the upper airway open.11 Recently published guidelines from the AADSM and the American Academy of Sleep Medicine recommend the use of oral appliances for the treatment of OSA.12
“Physicians agree that oral appliance therapy in the hands of a qualified dentist using the proper protocol is the first line of treatment for mild and moderate obstructive sleep apnea. Dentists now have the experience and the wonderful successful treatment outcomes to prove that we can and will be educated properly, and that we can be a very valued and significant part of the medical team to treat sleep-related breathing disorders,” notes Dr. Smith.
In Dr. Kaspers’ practice, he sees many adults for TMJ for which he corrects occlusion to get the patient into a seated condylar position to protect the musculature and bony structures of the teeth before making an oral appliance to fix the closed airway. “We’ve taken on a different approach with a lot of the adult patients in the sense that many of them that are coming to us are having structural problems and they have their musculature really starting to break down, so we want to get them asymptomatic so that they can go into an OSA appliance to get a good night’s sleep.”
Neil Park, DMD, Vice President of Clinical Affairs for Glidewell Laboratories, notes that bruxism and clenching are closely associated with sleep disorders, which is important for dentists to understand, especially those treating occlusal disorders with appliances. “Sleep appliances are based on the well-established principle of advancing the mandibular position in order to open the oral-pharyngeal airway. For this reason, most of the appliances with which I am familiar attach to both upper and lower arches and have some type of mechanism to hold the mandible in a predetermined advanced position.”
Mr. Dyer adds that there are many options currently available and selecting a device should be based on the individual patient’s needs. “In my case, the DynaFlex Dorsal was the best option. With a deviated septum, I breathe through my mouth. The DynaFlex allows me to open or close my mouth and still provide an open airway.”
The Laboratory Perspective
Dental practices rely on dental laboratories for a variety of services ranging from engineering dentures and crowns to providing assistance in selecting and creating oral appliances for patients with sleep-disordered breathing. “Labs are a critical partner in the process. They can help recommend appliances for unique cases,” says Mr. Dyer.
Dr. Park agrees that dentists who screen for and treat sleep apnea must maintain an excellent relationship with a trusted laboratory. “From assisting with training to providing screening equipment and appliances, this partnership is key to successfully incorporating this treatment modality into your practice.”
Dr. Ataii explained that his transition into sleep dentistry was not an easy one, but rather a bumpy road. After convincing his peers and patients that screening and treating for snoring and sleep apnea should be integrated into his practice, he then partnered with Sleep Oracle, a service provider that helps his practice reduce the amount of obstacles that are inherent in dental sleep medicine. “I now enjoy a less bumpy road since I have engaged with a company that helps my practice address and manage the various moving parts related to sleep dentistry, such as sleep testing services, clinical guidance, medical billing, and the various sleep appliances to choose from.”
The First Step
Before a dentist can truly be immersed in the world of sleep dentistry and integrate it into general practice, the most important step is to obtain the appropriate education.
“Sleep apnea is not an area in which many dentists have had formal training. Today there are many good places to begin to get the required education to ethically, successfully help patients with sleep apnea,” says Dr. Radz.
The AADSM offers leading and cutting-edge educational opportunities for dentists who want to become more involved in dental sleep medicine, and the courses are recognized by the American Dental Association. The AADSM offers an essentials course, held several times per year around the country, which provides a basic understanding of OSA, treatment options, and oral appliance therapy. They also offer Q&A webinars, online modules, practice management support, and online study clubs where dentists can earn CE more conveniently. In addition, they offer an educational "Board Review Course" to help dentists prepare for the ABDSM's certification examination to become a diplomate of the American Board of Dental Sleep Medicine, which is the highest recognized certification in dental sleep medicine.
“The important thing over all of this is the dentist’s understanding that the educational piece is so important. You can’t shortcut that. The AADSM has always been in lockstep with the physicians in our community, and we always knew from the very beginning that this is the key to the growth and flourishing of dental sleep medicine—to be a valuable part of this medical team,” notes Dr. Smith. “Not everybody needs to treat OSA, but the dentist is in the perfect position to screen for it and move the patient forward in the diagnostic protocol. So if they decide they do want to be involved and treat, then there is a myriad of educational opportunities available to get them prepared to treat this with oral appliance therapy.”
Once the educational aspect is achieved, the dentist must develop and maintain relationships with sleep physicians to create a collaborative effort for their patients.
The Collaborative Team
The sleep dentist and sleep physician’s partnership is one that maintains close contact. Dr. Smith notes that OSA is a medical condition that can only be officially diagnosed by a physician. Although it can be treated by dentists using oral appliance therapy, “they must be part of a medical team in which a patient’s physician is involved. It’s incumbent on the dentist to create the relationships with their community physicians so they can treat the patient properly.”
For the best possible treatment outcomes, it is also important for the dentist to find physicians with similar ideals in treating these patients, as well as formal education in this area.
“I would highly recommend that dentists take time out to interview ear, nose, and throat specialists to see which ones are more progressive in their thinking, so that the dentist can find somebody that will embrace the development of the airway or the handling of the airway in a manner that he or she would want them to address,” says Dr. Kaspers.
As Dr. Smith emphasized, sleep-disordered breathing is an epidemic, and we now know that the average person sleeps for 30% of their lives—a frightening percentage for someone with sleep-disordered breathing. But there’s hope for the future. This condition is manageable, and when recognized early and treated correctly, dental professionals can not only improve the quality of life for affected patients, but they can also save patients’ lives.
“I do think that we have to try to treat OSA in the early stages in a growing individual where we can improve their airway considerably, so they don’t have to endure having to wear a CPAP or even an OSA appliance. If we can handle it in their youth while they’re growing, it makes all the sense in the world. So the more we can better educate the dental profession, the better off we are going to be,” concludes Dr. Kaspers.
1. Garcha PS, Aboussouan LS, Minai O. Sleep-Disordered Breathing. Cleveland Clinic Center for Continuing Education. 2013. https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/sleep-disordered-breathing/ Accessed March 14, 2017.
2. American Academy of Dental Sleep Medicine. About Dental Sleep Medicine. https://www.aadsm.org/whatisdentalsleepmedicine.aspx. Accessed March 14, 2017.
3. National Sleep Foundation. Snoring and Sleep. https://sleepfoundation.org/sleep-disorders-problems/other-sleep-disorders/snoring. Accessed March 14, 2017.
4. American Academy of Dental Sleep Medicine. Snoring. https://www.aadsm.org/snoring.aspx. Accessed March 14, 2017.
5. American Academy of Dental Sleep Medicine. Obstructive Sleep Apnea. https://www.aadsm.org/sleepapnea.aspx. Accessed March 14, 2017.
6. American Academy of Dental Sleep Medicine. New Study Shows Dental Appliance Successful in Treating Patients with Severe Sleep Apnea. https://www.aadsm.org/articles.aspx?id=1185. Accessed March 14, 2017.
7. Balasubramaniam R, Klasser GD, Cistulli PA, Lavigne GJ. The Link between Sleep Bruxism, Sleep Disordered Breathing and Temporomandibular Disorders: An Evidence-based Review. Journal of Dental Sleep Medicine. 2014;1(1):27-37. https://dx.doi.org/10.15331/jdsm.3736. Accessed March 14, 2017.
8. NHLBI (National Heart, Lung, and Blood Institute) National Sleep Disorders Research Plan, 2003. Bethesda, MD: National Institutes of Health; 2003.
9. Joshi N, Hamdan AM, Fakhouri WD. Skeletal Malocclusion: A Developmental Disorder With a Life-Long Morbidity. J Clin Med Res. 2014;6(6):399-408.https://dx.doi.org/10.14740/jocmr1905w. Accessed March 14, 2017.
10. Maspero C, Giannini L, Galbiati G, et al. Upper airway obstruction in class II patients. Effects of Andresen activator on the anatomy of pharyngeal airway passage. Cone beam evaluation. Stomatologija, Baltic Dental and Maxillofacial Journal. 2015;17:124-130. https://www.sbdmj.com/154/154-04.pdf. Accessed March 14, 2017.
11. American Academy of Dental Sleep Medicine. Oral Appliance Therapy. https://www.aadsm.org/oralappliances.aspx. Accessed March 14, 2017.
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. J Dent Sleep Med. 2015;2(3):773-827.
13. Boyd K, Sheldon S. Sleep Disorder Breathing: A Dental Perspective. In: Sheldon S, Kryger M, Ferber R, Gozal D, eds. Principles & Practice of Pediatric Sleep Medicine. 2nd edition. Elsevier-Saunders; 2014:275-280.
Pediatric Sleep Dentistry: Why More Dentists Need to Get Involved
Kevin Boyd, DDS
Sleep-disordered breathing may not always be thought of as something that affects children and adolescents, but treating this condition in the early stages of life can prevent an adulthood filled with sleepless nights, constant daytime exhaustion, and various associated comorbidities.
According to Kevin Boyd, DDS, who maintains a private pediatric dental practice in Chicago, a competent workforce with specialty training and knowledge of pediatric behavior is desperately needed. “We need general dentists to get trained in understanding the importance of how malocclusion can relate to sleep and airway health competence. The demand is so huge. For me, I’m focused on pediatrics, but when I say this, I mean it for teenagers and adults too.”
He explains that, although dentists are the first opportunity to assess risk and intervene, the number of available dentists in the current workforce that can assess pediatric needs is insufficient. They need to understand how to create jaws that are conducive to habitual nose breathing, especially during sleep.
“Managing the jaws, the mid-face, and the mandible, and getting them properly aligned and proportional can be conducive to keeping the airway healthy,” notes Dr. Boyd.
He also maintains that continuing education is key, as sleep dentistry is not taught in dental schools and rarely taught in specialty training residency programs for both medical and dental residents. Although sleep medicine is still in its infant stages, dentists can start becoming better informed simply by reading the current literature. Dr. Boyd coauthored a chapter in a pediatric sleep medicine textbook that explained how dentists can mitigate issues associated with airway disease in children by intervening and helping their jaws grow early in life.13 Both he and Marianna Evans, his orthodontist research partner at the University of Pennsylvania, deem this practice “preorthodontics.”
His goal is not necessarily to straighten teeth, but to use orthodontic treatments, such as expanders, to improve the airway. He also notes that dentists must know what to look for in both children and adult patients.
“What dentists can do is also develop an understanding that if they see malocclusion or TMJ in their pediatric or adult patients, they should immediately suspect that this person is at-risk for or has possibly already developed airway disease. TMJ is very seldom independent of airway and breathing problems. Malocclusion, crooked teeth, and poorly aligned jaws almost always coexist with airway disease or susceptibility to future airway disease,” cautions Dr. Boyd.
Asking the Right Questions
Not all patients who snore have OSA, but they could be on their way to getting it, and this is an indication that the healthcare professional should be asking certain questions. Does your child wet the bed? Does your child grind his or her teeth? Does he or she sleep with his or her mouth open? Does your child have nightmares? Can your child wake up unassisted in the morning?
“These are all really important questions that anybody involved with children, whether they are a podiatrist, chiropractor, or speech pathologist, should be asking,” adds Dr. Boyd.
Dr. Kaspers agrees that it is the responsibility of the healthcare professional to be asking the right questions. He explains that if a scan shows a constricted airway in a pediatric patient, he will ask the parent: does your child take a long time when eating or chew his or her food almost excessively? “The airway is incredibly small, and the child may have experienced a choking event at one point or may have difficulty taking pills. It has everything to do with the fact that the airway is so small, and they don’t want to have the feeling that they can’t get a breath.”
Having dealt with pediatric patients for decades, Drs. Kaspers and Boyd agree that early intervention is necessary. “It’s time for more dentists to develop competence and help resolve the problem early in life,” says Dr. Boyd.