Sleep apnea: A new frontier?

Oct. 1, 2005
We learn something new every day! We do not just clean teeth. Or do we? How many times do we dread the next one-hour visit with a patient who “fights” with their tongue? The tongue is fighting the very hand that is helping their mouth to recover from biofilm invasion.

We learn something new every day! We do not just clean teeth. Or do we? How many times do we dread the next one-hour visit with a patient who “fights” with their tongue? The tongue is fighting the very hand that is helping their mouth to recover from biofilm invasion.

What I did not know until recently was that these patients may be suffering from a serious condition called sleep apnea. A famous football player was diagnosed and died from sleep apnea at the age of 30 in December 2004. Do hygienists daily view conditions leading to sleep apnea in our patients before the symptoms appear? I say we do!

Besides noticing enlarged tongues and tongues with different shapes, what is our next step of action? What tools are out there for us to use to screen for sleep apnea? A known fact of sleep apnea is that it takes eight years off one’s life.

If we take digital X-rays to check for decay on hard tissue and palpate soft tissue for lumps and bumps, why don’t we incorporate the head and neck exam to check the airway? Without air, we cannot survive. So, what is a dental hygienist to do? We only have so much time to screen patients for abnormalities. Who are these sleep apnea patients?

In a definition taken from, the Greek word “apnea” literally means “without breath.” The three types of apnea are obstructive, central, and mixed. Of the three, obstructive is the most common. Despite the difference in the root cause of each type, in all three people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.

Untreated, sleep apnea can cause high blood pressure and cardiovascular disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes. Fortunately, sleep apnea can be diagnosed and treated. Several treatment options exist, and research into additional options continues.

A pharyngometer uses acoustic reflection to map the oral airway. This tool sends sound waves down the throat, noting its cross-sectional area, collapsibility, and problem spots. Treatment involves oral appliances, which permit the dentist to position the airway correctly. Acoustic reflection also monitors the physiological changes in the airway as the oral appliance is introduced. This constant reassessment allows for maximum airway patency (retention of muscle tone assuring the airway stays open).

By using the pharyngometer invented by a dentist, a dental hygienist can add this to his/her list of offered services for the practice.

The patient is sent home after the initial pharyngometer/rhinometer screening and during the oral appliance treatment with an ambulatory sleep study called the Watch PAT - 100. This is a patient-friendly home-based study device. The purpose of the study is to monitor the patient’s breathing while sleeping. The patient takes home the device and the device tracks the sleep patterns of the patient.

Dental practices that target sleep apnea

I interviewed two dentists, one in California and one in Pennsylvania. Both were equally excited about their practices’ role in helping the medical community treat sleep apnea. Dr. Bryan Keropian is located in Los Angeles. He states most patients are not happy with the current mouth sleep apnea device called the C-pac. Dr. Keropian believes the new frontier for sleep apnea detection for the average dental patient is using the pharyngometer. He is elated that he is “screening and saving lives every day.”

Dr. Keropian states every dentist should have this device with a portion of his/her practice dedicated to treating sleep apnea. If not, refer to a dentist who does. How do patients learn about sleep apnea? Usually via referrals or mailings.

He also points out that the California practice act states dentists treat the teeth, gums, and the surrounding structures that affect them. Just recently, the Academy of Sleep Medicine published an article that said the best treatment for sleep apnea was a dental mouthpiece.

Dentists have a moral responsibility to the health of their patients by making the mouthpiece to sustain open airways. Dr. Keropian said, “The treatment of sleep apnea has been handed to the dental community.”

Dr. Tammy Balatgek of Pennslyvania started her TMJ therapy/sleep apnea practice last March. She draws from her current patient base to go from general dentistry to treating this sleep disorder.

“I am changing their lives,” she said. For example, Dr. Balatgek said a periodontist colleague was going through a divorce, was very depressed, and just not doing well. Because of her training, she asked a simple question that forever changed his life. She asked, “How do you sleep?”

Dr. Balatgek recognized that the periodontist had symptoms of sleep apnea. She then proceeded to treat him. The root cause of his emotional state was poor sleep. By simply treating him, his symptoms disappeared and he experienced a renewed life! The root cause of his problems was addressed.

Most physicians, Dr. Balatgek said, will medicate their patients with anti-depressants, overlooking the simple root cause by not asking, “How well do you sleep?”

I asked her how dental hygiene benefits from screening for sleep apnea patients? Dr. Balatgek quickly responded, “Oh, your profession can do so much to participate with the sleep apnea screenings.” She said some hygienists may see this as an added task that burdens their day. But taking only five minutes to use the computer to screen airways is such a life-saving service. She purchased more than one device for her office so there is no need to transfer the device from room to room.

I would agree this is key to helping save lives, but knowing how busy a hygienist’s day already is, there would need to be in place some key elements to incorporate such an added service. I am a big advocate of added services for patients, especially if a service helps to save a life or add eight years to our patient’s life.

Signs to look for are swollen tonsils or adenoids, allergies, inflamed sinus membranes, an anatomically small airway, or a combination. An oral airway obstruction occurs because of malocclusion, obesity (excess fat on the neck and chest), a hormonal imbalance/deficiency, pregnancy, an anatomically small airway, or combination. The sounds of snoring that a bed partner may hear are the result of pharyngeal tissues vibrating against one another. To sufficiently oxygenate the body, the air must force its way through the airway, partially or fully obstructed due to loss of patency. Gasping, choking or spasms and subsequent awakening are the body’s reaction to loss of oxygen and are indicative of a complete obstruction of the airway. Any obstruction of the airway is extremely detrimental to the intricate functioning of the cardiovascular, lymphatic, gastrointestinal, and nervous system.

Questions to ask include: Do you snore? Do you feel rested in the morning? Do you suffer from morning headaches? Do you have acid reflux? Do you have high blood pressure?

The way to implement pharyngometer screenings is to first have a reason for your patients to come back for the sleep apnea screenings. The questions above and some clinical screening will flag that your patient’s need to come back for “sleep apnea” screenings. The hygienist should conduct this service appointment. Sleep apnea screening should be scheduled for one hour.

This hour is spent retrieving history, what past sleep devices have been used and their effectiveness. First, begin by putting your patient on the device for five minutes, and then spend the rest of the time educating your patient about sleep apnea.

The dental hygienist can also take the impression for the sleep apnea appliance. The dentist reads the graph and delivers the mouth piece to the patient for the completion of the treatment.

The hygienist must become familiar with insurance coding and the cost of treatment. Negotiate with your doctor to incorporate added services in the hygiene department. This added service as is as much a needed service in the community of health as prophy appointments, if not more!

Coding for sleep apnea cases

Using the cross medical/dental billing codes below will help offset costs to the patient when you can bill medical and dental codes at the same time.

The medical code usage is CPT 95806 (Watch-PAT 100 home sleep study) and ICD 780.53 (Obstructive Sleep Apnea with Hypersomnia).

The dental code usage is D21110 (Oral Appliance), D21089 (Oral Appliance), D99070 (Diagnostic Study Models), D92520 (Pharyngometer-Laryngeal Function Study), and D92512 (Rhinometer-Nasal Function Study).

Please note that all dental patients must be first referred by a medical doctor to a dental office for the treatment of sleep apnea.

Victoria DaCosta, RDH, BS, is founder and president of Hy-Tech Solutions. A practicing dental hygienist for 18 years, DaCosta is a speaker, author, consultant, and an expert in the design of medical/dental software. She is also on the new technologies committee for the California Dental Hygienists’ Association. DaCosta can be contacted at