How sleepy are they?
In recent years, the diagnosis of sleep apnea has led to a collision of the dental and medical professions. How many patients during an average clinical day do you see that have been diagnosed with obstructive sleep apnea (OSA)?
Obstructive sleep apnea: Recognizing the risks in the hygiene operatory
By Jamie Collins, RDH, CDA
In recent years, the diagnosis of sleep apnea has led to a collision of the dental and medical professions. How many patients during an average clinical day do you see that have been diagnosed with obstructive sleep apnea (OSA)? How many have not yet been diagnosed and may be suffering from some of the signs or symptoms? Many symptoms are present for years before the patient finally obtains a referral for evaluation. As hygienists, who daily look at the back of the throat, we should be aware of what to look for clinically and ask the appropriate questions regarding the possibility of obstructive sleep apnea.
I was guilty of knowing only the very basics about obstructive sleep apnea without taking the time to learn the possible risks associated with untreated apnea. I spent years elbowing my husband at night when he would snore and gasp in his sleep. Finally, we asked his primary physician for a referral for a sleep study. At this time, I started researching it more and was surprised to discover the health risks associated with apnea. We realized my husband had many of the symptoms associated with OSA. He is in the company of an estimated 22 million Americans who suffer from sleep apnea.
What is OSA?
Obstructive sleep apnea is the most common type of sleep disorder associated with breathing. It is characterized by episodes of cessation or a significant decrease in airflow during sleep. OSA is a condition where the muscles of the tongue and throat relax and the tissues block the airflow to the lungs in varying degrees. The tongue relaxes against the soft palate, and the soft palate relaxes against the back of the throat. Obstructive sleep apnea is also referred to as obstructive sleep apnea syndrome, or obstructive sleep apnea hypopnea syndrome. Of the estimated 22 million Americans with sleep apnea, it is estimated 80% of those with moderate to severe apnea are currently undiagnosed.
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Hygienists can often be the first to recognize and lead patients to their physicians for further evaluation of OSA. Alongside the brochures about sealants and periodontal therapy in my operatory, I have a brochure on snore appliances. It is a great conversation starter, mostly with men over 40 years of age. Many of them comment on how they snore and would consider a snore appliance for their wives' sake. Sound familiar?
Obstructive sleep apnea can affect patients of any age. However, it is most common in men over 40. Physical examinations of patients that are affected with OSA are generally normal, with the exception of obesity, hypertension, and an enlarged neck circumference, in men greater than 17 inches, and women greater than 15 inches. The increasing waistlines and obesity rate in America are a leading factor in the risk of developing OSA. A patient may snore and have obstructive sleep apnea, but we are not able to make the diagnosis of OSA from a dental standpoint. We can only encourage our patients to seek medical evaluations if it is suspected.
Once sleep apnea is suspected, the primary physician will often refer the patient for an overnight sleep study, or polysomnography, to confirm the diagnosis of OSA. Testing usually requires an overnight stay at a sleep laboratory for testing and diagnosis. Occasionally a sleep study may be performed at home with evaluation equipment and read by the physician. In accordance with the American Academy of Sleep Medicine guidelines, the diagnostic polysomnography should include the following:
- Sleep stages are recorded with an electroencephalogram, electro-oculogram, and a chin electromyogram.
- Heart rhythm is monitored.
- Leg movements are recorded.
- Breathing and airflow are monitored, at the nose and mouth, including effort and oxygen saturation.
- Breathing patterns are analyzed for apneas and hypopneas.
Obstructive sleep apnea is becoming more frequently diagnosed in children and is recognized as a cause of daytime behavioral and attention problems. Children are more difficult to recognize and diagnose for OSA. However, other symptoms often accompany and are used in conjunction during the diagnosis. In addition to loud snoring, other signs may include failure to thrive, mouth breathing, enlarged tonsils and adenoids, problems sleeping, excessive daytime sleepiness, and behavioral concerns. The child may exhibit problems paying attention, aggressive behavior, hyperactivity, and may be having problems in school. Diagnosing OSA in children is often left to a pediatric ear, nose, and throat specialist, and diagnosis is made from symptoms and the presence of enlarged tonsils and adenoids. Rarely, but if necessary, a pediatric sleep study may be performed.
Occasionally, underlying medical conditions may lead to OSA in children, and these may include allergies. Children with Down syndrome are at increased risk for OSA and should be monitored. A common treatment for pediatric obstructive sleep apnea is to perform surgery to remove the tonsils and adenoids.
If the problem arises from allergies, a nasal steroid may be prescribed to alleviate the nasal obstruction and aid breathing. My son had inherited large tonsils and narrow airway from his dad and was a loud snorer as well. He recently was diagnosed with pediatric OSA and had his tonsils and adenoids removed. Immediately, his breathing improved and snoring stopped. His sleep patterns improved, and he was no longer waking up nightly. Even after having a husband with OSA I did not realize a child could develop OSA as well. We thought for years he was just a snorer and bad sleeper without realizing the possibility of OSA.
How many children have you seen clinically and take notice of the size of their tonsils while working? It is worth mentioning to the parents that they have the physician evaluate the child if other signs of pediatric OSA are present.
Dental hygienists often spend the most time visiting with patients during the dental visit. By taking the time to look clinically and asking pointed questions concerning the patient's well-being, we are often able to alert the patient to suspected concerns that may be easily treated. Both young, old, and in between are all at risk of having obstructive sleep apnea, and hygienists may help prevent the health implications associated with it.
Jamie Collins, RDH, CDA, is a practicing clinician, and educator at the College of Western Idaho. She led state curriculum development and revision in addition to developing online dental courses as well as conventional courses. She has recently contributed to multiple textbooks, with more in the works. Contact Jamie at firstname.lastname@example.org.
Symptoms of obstructive sleep apnea
When left untreated, obstructive sleep apnea can lead to an increased incidence of hypertension, chronic heart failure, type II diabetes, depression, atrial fibrillation, stroke, and other cardiovascular diseases. With those risks in mind, hygienists need to be vigilant in recognizing the signs and symptoms for patients and loved ones.
Clinical symptoms we see may include a high arched palate, large degree of overjet, enlarged or "kissing tonsils," and narrow lateral airway walls (which is an independent risk factor for men only). Other findings may include congestive heart failure, pulmonary hypertension, stroke, metabolic syndrome, type II diabetes, and hypertension (which is present in nearly 50% of OSA patients). When we recognize some or all of the symptoms while performing our exams clinically, it is important to ask about the symptoms we cannot see physically. Most of our patients are not in the health-care profession, and many are not aware of what signs to look for.
The most frequent initial complaint from a patient is snoring, which can be disruptive to others in the household. Other signs of obstructive sleep apnea may include gasping or choking that often awakes the individual from sleep, insomnia or tossing and turning, witnessed apneas that sound like snorting that interrupts snoring.
Individuals may also experience daytime symptoms that can include a morning headache, dry or sore throat, gastroesophageal reflux, hypertension, and confusion in the morning. Changes in mood and personality may be present, as well as depression and anxiety, sexual dysfunction, and decreased libido. More commonly, the patient will complain of waking up tired, or excessive daytime sleepiness and fatigue. As OSA can gradually develop, never feeling rested and without energy becomes a "normal" feeling for these individuals, and they may not recognize it as a problem on their own. Sometimes you never realize how bad you felt until you feel better.
Treatment options for sleep apnea
Once a definitive diagnosis of sleep apnea is made, management depends on the severity of the disorder. Those diagnosed with mild to moderate obstructive sleep apnea generally have more treatment options than individuals with moderate to severe OSA. Treatment options often are a combination of conservative therapy and prevention and utilizing mechanical treatments. A patient can manage or prevent OSA at home by avoiding smoking, alcohol, and other sedatives (especially four to six hours prior to bedtime). Avoid sleep deprivation and avoid sleeping in the supine position or sleeping upright, especially for obese patients.
Medications have not been shown to be effective for treatment of OSA. However, some central nervous system stimulants such as modafinil and armodafinil have been used in conjunction with mechanical management.
A fair percentage of my patients that have been diagnosed with obstructive sleep apnea use a CPAP machine (continuous positive airway pressure) nightly. The CPAP is most effective for treating OSA as it blows air down the throat during sleep to keep the airways open. CPAP machines consist of a mask that fits over the nose, or nose and mouth, a motor that blows air, and a large cannula that connects the mask to the motor. Many CPAP machines will include a humidifier that will moisten the air delivered during treatment.
CPAP machines may be the most effective treatment, but a patient will often complain they take time to get used to, as well as the side effects. Most side effects are minor and may include sores over the bridge of the nose, stomach bloating (from increased air pressure), chest discomfort, and feeling confined from the facemask. Nasal congestion and sinusitis are often common, as is xerostomia. Increased xerostomia also means increased periodontal and caries risks! Make recommendations to help prevent this, such as fluoride and saliva-stimulating home-care products.
Individuals diagnosed with mild to moderate obstructive sleep apnea often have the option of using an oral appliance for management of the disorder. This is often where the medical and dental professions work in conjunction. If the CPAP has not helped or the patient has chosen the option of using an oral device, the dental office will take the impressions and have a lab fabricate the oral appliance. The appliances are fitted and adjusted by a dentist and worn by the patient at night.
The mandibular advancement device (MAD) is the most widely used oral appliance for treating OSA. It appears similar to an occlusal guard. The devices are custom fit and snap over the maxillary and mandibular arches. Either hinges or thick bands advance the mandible forward to open the airway and help to position the jaw and tongue forward, thus preventing the tongue from obstructing the airway. The two main types of mandibular advancement devices are the TAP and EMA appliances. The TAP appliance is made with a hinge on the anterior, and the EMA utilizes thick bands for jaw advancement. Both work very well and are adjustable in positioning the jaw forward to a comfortable and effective position.
Tongue stabilizing devices (TSD) are the other type of apnea appliance to treat OSA. This device holds the tongue forward, using suction to prevent it from falling back and obstructing the airway while sleeping. Tongue stabilizing devices have an adjustment period for many patients, but also have some benefits. Individuals with periodontal disease, TMJ disorders, and edentulous patients may benefit since they do not snap onto the dentition. This type of device does not require impressions of the oral cavity as they are not custom fabricated.
Often, medical insurance plans will cover a portion of the mandibular advancement and tongue stabilizing devices. Insurance coverage usually requires a sleep study and physician's prescription for authorization and coverage.
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