Snoring and Sleep Apnea - A Nuisance or a Disease Continuum?
Why the dental office should be the number one portal in screening and identifying patients at risk – the Hygienist and Dental team play a huge role!
Two-thirds of partnered adults say their other half snores, while 6 out of 10 of all adults (59%) say they snore. Sleep Apnea may be present in 20-40% of the adult population that experience snoring.
According to the U.S. Department of Health and Human Services, more than 45 million Americans suffer fromsleep apnea, a disorder that causes a person to briefly and repeatedly stop breathing during sleep.Obstructive Sleep Apnea (OSA) is a debilitating, oftenlife-threatening sleep disorder an estimated 800 thousand patients are being diagnosed with OSA per year in the USA and approximately 10% being treated.
Primary Care practices are not actively screening patients for OSA which leaves a large void in the number of patients being identified with this killer disease. OSA has directly been linked through numerous research papers to co-morbidities such as Stroke, Heart Disease, Hypertension, Impotence and Diabetes. For those patients who have been diagnosed and have had Continuous Positive Airway Pressure (CPAP) recommended, may be intolerant of the therapy and are currently going without therapy. There are millions of patients who need treatment, including those who cannot tolerate their CPAP machines and are looking for alternatives. The Dental practice is a prime portal to not only screen and identify patients at risk, however to offer clinically proven therapy with oral appliances.
So how does a Dental practice start to implement Oral Appliance Therapy as a part of their treatment services?
It starts with education for the dentist and the dental team. Currently there are many continuing education courses available on the topic of Dental Sleep Medicine and Oral Appliance Therapy, usually a two to three day course with subsequent workshops and follow up that is essential. I must emphasize, in order to be successful with implementation the entire team needs to be involved - Dentist, Hygienist, Assistants and Front Desk staff.
Following the education starts the “Implementation” process which involves asking questions,observing, communicating, initiating systems and offering solutions. The questions should start at the front desk when a patient checks in for their re-care appointment. The following questions should be added to your patient history update form:-
- Have you been told you Snore?
- Are you excessively tired during the day?
- Have you ever had a Sleep Study?
- Have you been diagnosed with Sleep Apnea?
- Do you wear a CPAP?
If a patient answers “yes” to any of the questions above the conversation should be picked up by the Hygienist. There are also some tell tale clinical signs to look for in these patients like wear facets (Bruxing), periodontal disease, a large neck, obesity, scalloped large tongue, red & inflamed uvula and enlarged tonsils. On identifying any of these clinical signs the patient should be directed to fill in a questionnaire called the Epworth Sleepiness Scale. This will identify how “sleepy” the patient is in their regular daily routine.
It is likely that patients will tell you “Oh I just Snore when I am tired, I do not have Sleep Apnea” well how do they know if they haven’t been tested or diagnosed? Snoring is the beginning of a disease continuum that will develop into apnea if therapy is not initiated. Apnea will get worse with age, bad diet, weight gain and an unhealthy stressful, lifestyle which these days can be so common. Unfortunately, many people do not realize that they suffer from sleep apnea unless someone else brings it to their attention.
Following the screening process a dentist cannot diagnose OSA. The gold standard in care is to refer your patient to a Sleep Laboratory for a Diagnostic Sleep Study known as a Polysomnogram (PSG). This is where you will start to build a mutual referral relationship with your local laboratory and reporting Sleep Physician. The multidisciplinary referral pathway should be that you refer your patients for a diagnosis and providing the results fall within the American Academy of Sleep Medicine (AASM) guidelines for oral appliance therapy - mild to moderate apnea with no co-morbidity, the patient should be referred back to you with a prescription for an oral appliance. This is important for reimbursement too. Oral appliances are also recommended for severe OSA patients if they cannot tolerate their CPAP, although they should always try CPAP first.
Home Sleep Testing (HST) is becoming more and more popular and there are companies that offer an interpretation service for patients who will not or cannot to go to a Sleep Laboratory. There are a wide range of HST devices available to the Dental market and can be used for screening, diagnosis (providing they have a certified physician interpret the report and sign off on the treatment recommendation) and the main function in the dental office, is used to check the effectiveness of the oral appliance therapy and ongoing efficacy.
Once you have a diagnosed patient who is dentally appropriate for oral appliance therapy, you are ready to do a full patient examination, evaluation and work up including impressions and a bite registration with protrusive and vertical dimension. It would be at this stage that you check their medical insurance and benefits to see if they are covered for this type of treatment.
There are numerous custom fitted oral appliances available on the market all with varying degrees of efficacy, patient comfort and cost. Consider fabricating and dispensing only FDA cleared devices when treating OSA in order to secure insurance reimbursement, oral appliance therapy is covered by Medical Insurance not Dental insurance. Medical billing is becoming a more common necessity in the Dental practice for a variety of treatments and procedures. The learning curve and process of medical billing and cross coding can be somewhat consuming however there are software solutions available and also companies that will handle the entire process for you which is very helpful, especially for those just getting started!
Once a patient is fitted with an oral appliance a follow up protocol is essential, you have to ensure that the appliance is adjusted to the optimum position whereby snoring is eliminated and the apnea is reduced significantly. Initially this is done with an HST device and ultimately when efficacy has been achieved refer the patient back to the sleep laboratory for a sleep study (PSG). The HST and PSG results should correlate well which gives the Sleep Physician confidence that oral appliances are proving effective and in some cases a good alternative to CPAP.
Oral appliance therapy can be truly life changing for these patients and being able to change the quality of someone’s life is extremely powerful and rewarding. I have seen many tears and hugs from grateful patients who didn’t even realize how bad they felt until they started to feel the benefits of their treatment.
In summary a large part of this treatment can be performed by the Hygienist working closely with the Dentist and a multidisciplinary approach. Dental Sleep Medicine is a substantially rewarding practice and our country is in desperate need of more awareness and treatment options.
About the Author - Ashley Truitt, RDA, BBA
Ashley has been in the Dental industry for the past 25years. She is the Owner/Director of Dental Sleep Medicine Worldwide an education and consulting organization dedicated to the advancement and awareness of Sleep Apnea in the Dental office. She is a presenter at continuing education courses on sleep apnea, and for the updated schedule you can visit www.SleepComplete.com
For further information on how to successfully implement Dental Sleep Medicine into your practice contact
your Henry Schein Field Sales Consultant for more details.
1. National Sleep Foundation 2005 Poll
2. US National Department of Health and National Services
3. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in adults. J Clin Sleep Med 2009;5(3): 263-. 276. Page 2. Journal of Clinical Sleep Medicine, Vol.5, No. 3, 2009
4. The Epworth Sleepiness Scale – Key 1997 ESS Dr Murray Johns
5. American Academy of Sleep Medicine Practice Parameters – Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliance Therapy with Oral Appliances: Kushida C, Morgenthaler T, Littner M, Alessi C, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer J; American Academy of Sleep Medicine. SLEEP, 2006 Feb 1; 29(2):240-3
6. The American Academy of Dental Sleep Medicine, The Ins and Outs of Oral Appliance Therapy.