Recent studies show that OSA affects 18 million Americans, with estimates showing that more than 80 percent of moderate to severe cases remain undiagnosed.
New initiatives to enable dentists to provide affordable OSA screenings chairside have become paramount to identifying and treating patients with previously undetected sleep disorders that affect breathing.
How dentists can help identify undiagnosed OSA
Dental practitioners are in an excellent position to screen for sleep apnea to help identify these undiagnosed (and therefore, untreated) OSA patients. They:
have direct observational access to the physiological structures of their patients' upper airways
are already screening chairside for other health conditions that can be easily spotted during a dental visit
may see these patients more frequently than primary care physicians will, with nearly one quarter more likely to see a dentist than a doctor over any given time period
A recent study followed dental hygienists in a community-based practice to see if OSA screening could yield reliable indicators for referrals.
Patients were assessed using the STOP-Bang questionnaire (a common sleepiness assessment tool used by physicians). They were also given an overnight pulse oximeter to take home to record trends in nocturnal blood oxygen saturation.
The study revealed that more than half of the patients assessed were found to be at "high risk" for having OSA. Followups with sleep specialists further confirmed the accuracy of these findings. When referred to a sleep specialist, a third of the most high-risk candidates (those who were shown as "high risk" for both assessments) followed through on a consultation.
As with screenings for oral cancer and hypertension, OSA screenings can be simple, inexpensive, and shouldn't add much more time to the patient's visit to the dentist. Dentists and patients alike stand to gain from OSA screening, especially with dental-related treatments for sleep breathing disorders gaining ground.
The emergence of dental sleep medicine to treat OSA
Maxillomandibular advancement (MMA) devices and other forms of oral appliance therapy (OAT) have been recently accepted as first-line treatments for sleep apnea, as well as upper airway resistance syndrome (UARS) and chronic snoring.
The American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine made joint recommendations last year showing support for OAT approaches. Oral appliances has been shown to be just as effective as continuous positive airway pressure (CPAP) therapy in treating sleep apnea and leading to healthy patient outcomes.
Dental patients also stand to benefit from having this assessment from an oral health perspective, which is good news for dentists; sleep apnea is also commonly associated with the following dental concerns:
periodontal disease (caused by untreated OSA's contribution to systemic inflammation)
Practitioners of dental sleep medicine now find themselves a critical point along a patient's continuum of care. It simply makes sense from the perspectives of dentists, patients, and public health advocates that OSA become a regular part of the dental screening process at every visit.
What about pediatric dentistry?
According to recent studies recognized by the American Academy of Dental Sleep Medicine, nearly one third of pediatric dental patients are not regularly screened for sleep breathing disorders.
In the same study, it was revealed that only 7 percent of pediatric dentists reported providing treatment for those patients who were diagnosed with OSA.
These are lost opportunities for the long-term care and treatment of pediatric patients. For those who did treat OSA in their patients, three quarters used maxillomandibular therapies, with the rapid palatal expander being the most common treatment.
Given the physiological mechanisms that lead to the development of sleep apnea (such as retrognathia, midface hypoplasia, adenotonsillar hypertrophy), it makes sense that pediatric dentists screen their patients for OSA to determine whether they already have sleep breathing concerns related to changes in their developing physiology.
How to screen patients for OSA
There are three approaches to consider.
Visual assessment of anatomical parameters:
- Mallampati classification. This visual assessment rates the crowding of the upper airway and can show potential cause for disordered breathing at night
- Acid erosion on teeth. Evidence of this suggests the presence of acid reflux, which has been shown to be correlated with underlying sleep apnea
- Evidence of oral breathing. Not only is breathing through the mouth a threat to good oral health, but it can also indicate the potential for a sleep breathing disorder
- Orthognathic classification. Occlusion caused by physiological misalignments can be associated with apnea
- Bruxism. Evidence of grinding or clenching can point to untreated, undetected problems with breathing during sleep
Patient interview to isolate chief complaints:
- Excessive daytime sleepiness. This may be easily observed at chairside, mentioned independently by the patient, or be a common response from patients when asked during the interview
- Difficult breathing in supine position. Nasal airway patency issues while reclining in the dental chair can be suggestive of sleep breathing problems
- Hypertension. If the patient mentions a sudden and unexplained rise in blood pressure, it may be evidence of untreated sleep apnea
- Snoring. Patients may not always admit to snoring, though some do. Meanwhile, others may not know they snore because they do not have sleeping partners. Ask them if their family members or bed partners have mentioned that they snore or witnessed unusual breathing patterns, pauses in breathing, or gasping at night which could reveal hidden sleep breathing issues
- Allergies or congestion. These can contribute to oral breathing during sleep as well as UARS and snoring. Both of these concerns should be pursued further to rule out potential sleep apnea
Use of common sleep apnea assessment tools:
- The Epworth Sleepiness Scale. This subjective questionnaire is short and simple, but can reveal how sleepy a patient is and can reliably identify those who may be at risk for sleep apnea
- STOP-Bang. This is another quick and reliable assessment instrument that helps to identify patients who are more likely to have sleep apnea
- GASP. This is Sound Sleep Health's own sleepiness assessment tool, a questionnaire the patient fills out to determine their risk factors for sleep breathing disorders (click on the free sleep apnea test link below to access the GASP)
What an OSA screening collaboration between physicians and dentists look like
While dentists cannot officially diagnose patients with OSA or other sleep breathing disorders, they can do the following:
Screen for sleep breathing concerns
Refer patients to sleep specialists for consultations when indicated
Recommend and choose (or build, for those dentists properly trained to do so) OAT devices for patients when prescribed by sleep specialist
Manage these patient's OAT progress over the long term, with regular follow ups and consultations
Manage other oral health concerns which may relate to the development of OSA (especially in pediatric patients)
Potentially, collaborate with sleep specialists when severe patients stand to benefit from combination therapy (the simultaneous use of CPAP with OAT)
Dentists who choose to work on the front lines of OSA detection stand to benefit not only with return patients needing additional long-term services, but with opportunities to help these patients improve their other oral health concerns by treating their sleep breathing disorders.
If you are a dentist in the Seattle area and you wish to learn more about OSA screenings, please consider joining Sound Sleep Health downtown on July 27 at its upcoming dental sleep medicine luncheon, when Seattle sleep physician Dr. Gandis Mazeika delivers a discussion on the topic of dental OSA screenings. Dr. Mazeika already works with several local dentists to provide patients with oral devices and is always on the lookout for more dental practices to which he can refer patients for therapeutic services for OSA. Click here for more information and to RSVP.
American Academy of Dental Sleep Medicine
American Sleep and Breathing Academy
"Mallampati Score," by Jmarchn (Own work) [CC BY-SA 3.0]