Treating sleep apnea: The role of dentists, primary care physicians

Obesity is a global epidemic well rooted in the U.S. and Western cultures. With recognition of the magnitude of this epidemic, it is important to promote obesity prevention by all health professions and disciplines. This will help to prevent further health complications, such as diabetes, heart disease and obstructive sleep apnea, as well as other sleep-related breathing disorders (SRBD).

When a person struggles to breathe during sleep, or stops breathing, additional stress is placed on the heart, leading to health risks. To further improve the health of our patients, dentists should work with primary care physicians (PCP). Here is why.

Screening for sleep apnea

Dentists and primary care physicians are the first line of detection and treatment for their patients. As a dentist, you see your patients more frequently than physicians. This is especially true when patients adhere to the recommended cleaning every six months. PCPs  often see their patients more frequently than physician specialists, such as cardiologists, neurologists, pulmonologists, etc.

Both dentists and PCPs have the opportunity to discuss a variety of concerns that affect their patients’ quality of life, well-being and potential health risks. A large number of patients with undetected and untreated sleep disorders pass through dental and PCP offices each day. For this reason, it is important to complete advanced training and continuing education courses. This will help you to better understand how best to embed practical assessments and referrals into routine care.

Dentists and PCPs should work with a referral system. This links the patient with a proper specialist for diagnosis, as well as treatment. They can also educate and consult the patient about healthy lifestyle choices to reduce risk factors associated with obesity and SRBD.

Evidence-based treatment of sleep apnea

After a diagnosis is made, the medical sleep specialist can recommend treatment. Possible treatment might include weight loss, positional therapy, continuous positive airway pressure (CPAP), oral appliance therapy or surgery. Combination therapy is also common to provide individualized treatment for the patient. This often includes CPAP with oral appliance therapy. When a dentist receives proper training and credentialing, they can effectively treat patients using oral appliance therapy.

Patients should receive ongoing reinforcement for healthy behaviors during routine office visits. This is regardless of the treatment or health professional overseeing treatment. 

Relationship between obese youth and sleep apnea

There is an increasing prevalence of children and adolescents with obesity causing a global health concern. While the effect of obesity on cardiovascular function has been investigated, little remains known about how it impacts obstructive sleep apnea in youth with obesity.

In a recent study from the American Journal of Cardiology, researchers looked at the influence of OSA on cardiovascular functional parameters in obese youth. The study looked at 44 obese patients and 44 age- and gender-matched control subjects. Every patient underwent polysomnography and cardiovascular assessment.

The study found that patients with obesity had:

  • Higher left ventricular (LV) mass/height 2.7,
  • Preserved LV systolic parameters.
  • Differences in LV diastolic parameters.
  • Increased PWV and systolic blood pressure at rest compared with control group.

For youth with obesity, 32 percent had obstructive sleep apnea. However, there was no correlation between obesity and the apnea-hypopnea index (AHI). The LV mass/height 2.7 significantly correlated with body mass index z-score whereas PWV correlated with AHI. The body mass index z-score for patients with obesity was an independent predictor for LV mass/height 2.7 and AHI was an independent predictor for higher PWV.

From this study we understand that both obesity and OSA influence cardiovascular performance in youth with obesity. And while obesity is associated with increased LV mass and reduced LV diastolic function, obstructive sleep apnea is associated with changes in arterial stiffness.

Add this to the list for reasons to not only treat sleep apnea, but also offer lifestyle change suggestions for children and adolescents to further prevent complications.

Guidelines for treatment of sleep apnea with oral appliance therapy

In the first official joint guideline from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), oral appliance therapy is recommended for the treatment of adult patients with obstructive sleep apnea (OSA) who are intolerant of continuous positive airway pressure (CPAP) therapy or prefer alternate therapy.

This AASM and AADSM guideline supports increased teamwork between physicians and dentists to achieve optimal treatment of patients with OSA. While their recommendations were published in 2015, it is important that we make sure we are familiar with them. Their recommendations are vital to our care for our patients with sleep apnea.

The AASM and AADSM have six recommendations for dentists to follow.

  1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD)
  2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE)
  3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD)
  4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE)
  5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE)
  6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE)

For more information on their recommendations, such as the summary for each, download the document. I hope this helps moving forward for a better understanding of what the AASM and AADSM recommend for treatment of sleep apnea with oral appliance therapy.  

Start planning for 2019: Sign up for these pain courses

If you’re like me then you like to plan ahead. There are times you might wish you knew about a dental sleep medicine (DSM) course sooner than the week before–believe me, I get it. Well, to help those who are planners, here are three DSM courses at the start of 2019 you can plan ahead for!

March 15-17, 2019, Orofacial Pain Mini Residency Session 1 in Atlanta. This is a comprehensive two-session, 38 CE Credit program designed to give dental practices the knowledge and guidance to fully incorporate orofacial pain treatment into their practice. The program is led by industry mentors Dr. Mayoor Patel, DDS, MS, RPSGT, D.ABDSM, DABCP, DABCDSM, DABOP and former AACP president Dr. Terry Bennett, DDS, D.ABDSM, D.ABCP, D.ABCDSM.

With an emphasis on hands-on learning, attendees gain the skills and confidence needed to be successful in all aspects of TMD & craniofacial pain treatment. The first session will consist of:

  • Neuroanatomy.
  • The concepts and fundamentals of pain.
  • Musculoskeletal disorders.
  • Neuropathic disorders.
  • Neurovascular disorders.
  • Hands-on examination and documentation systems.
  • Medical billing for TMD treatment.

April 26-27, 2019, The Appliance Course for Dental Sleep Medicine & TMD in Scottsdale, AZ. There are so many obstructive sleep apnea and TMD appliances in the dental market, so how do you know which one to choose for which patient? It might be a bit overwhelming, but that is where this lecture helps. The Dental Sleep Medicine and TMD appliance course is a two-day journey towards increasing your mastery of dental sleep medicine and TMD appliances. In this course you will learn:

  • The pros and cons of each major appliance, and which one is right for each patient.
  • How to develop communication protocols with patients and dental labs for more successful outcomes.
  • Comprehensive exams and hands-on bite registration techniques.
  • Triaging between sleep apnea and TMD treatment.
  • The latest medical billing policies, codes, and best practices for successful reimbursement.

June 14-15, 2019, Orofacial Pain Mini Residency Session 2 in Atlanta. Session two of the Orofacial Pain Mini Residency will cover imaging, pharmaceuticals, and adjunct therapy for orofacial pain. Therapy for craniomandibular disorders, orthotic therapy, and a review of other common orofacial pain conditions is covered before diving into hands-on injection therapy, and closing with sleep and pain, and case studies.

To learn more about upcoming lectures, please visit http://mpateldds.com/upcoming-lecture/. I look forward to seeing you an an upcoming lecture or mini-residency covering the topic of pain!