Choosing a Dentist for Sleep Apnea Treatment

Snoring and obstructive sleep apnea can be serious medical problems. Improperly treated obstructive sleep apnea can increase the risk for heart attack, stroke, diabetes and other serious illnesses. Choosing a sleep-disorders dentist who is qualified to work with your physician is essential to your health or the health of a loved one.

The dentist you choose to treat your problem with sleep disordered breathing must be properly educated and with adequate experience. Legally, any dentist can treat snoring and/or sleep apnea with an oral appliance, however, that does not mean that every dentist has the necessary experience and training to provide proper therapy. Because no special qualifications are required it is your responsibility to choose your dentist wisely.  A qualified sleep-disorders dentist should have:

• Appropriate knowledge of sleep medicine
• Adequate training in oral appliance therapy
• Experience with many different appliance types
• Solid relationships with local sleep labs and sleep physicians
• Current knowledge of emerging trends
• Ability to derive maximum insurance benefits for you
• A team approach with other professionals
• A proven follow-up system to ensure healthy results long-term
• In-depth knowledge of oral appliance research

Obstructive sleep apnea is a serious medical problem that has been associated with cardiac problems, high blood pressure, stroke, diabetes, ED, gastro-esophageal reflux disease, and numerous other medical problems. Neither snoring nor sleep apnea should be taken lightly, as your health is at stake. Recent research is beginning to explore the complex interrelationships between sleep apnea and these other medical problems. Management by a dentist should always involve interaction with your family physician, cardiologist, pulmonologist and/or endocrinologist.

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Snoring is no joke...

Almost half of adults snore. And the problem is worse with overweight persons.

Snoring occurs when there is a partial obstruction to the free flow of air through the mouth and nose. The sound occurs when loose structures in the throat, like the uvula and soft palate, vibrate as air passes over them. Snoring can get worse when the muscles in the back of the throat are too relaxed either from drugs that induce sleep or alcohol consumption. Snoring can also be caused by a large uvula and soft palate, nasal congestion, a deviated septum or other obstructions in the nasal and pharyngeal airways.In children, large tonsils and adenoids can be the cause of snoring. Pregnant women snore because of a narrowing of the airway and increased weight.

Can snoring be serious?

Snoring can be serious both socially and medically.

Snoring can disrupt marriages and cause sleepless nights for bed partners.

Medically, snoring can be the precursor of obstructive sleep apnea that has been linked to heart failure, high blood pressure and stroke. In its own right, snoring has been linked to Type II Diabetes. Sleep apnea usually interrupts loud snoring with a period of silence in which no air passes into the lungs. eventually the lack of oxygen and the increase carbon dioxide will awaken you forcing the airway to open with a loud gasp.

Ask your physician or dentist

You may not be aware of your snoring but your bed partner is! Seeking professional advice can help you both because snoring not only causes disruption in sleep it can also be a sign of obstructive sleep apnea.

If your child snores, speak to your pediatrician about the problem. Nose and throat problems as well as obesity may be the cause. Treating these conditions could help your child sleep better at night and help your child's mental and physical development to stay on track.

severity of snoring

Snoring is often graded from your bed partner's point of view:

• Grade 1: Heard only if you listen close to the face
• Grade 2: Heard in the bedroom
• Grade 3: Heard just outside the bedroom with the door open
• Grade 4: Heard outside the bedroom with the door closed

complications of snoring

Snoring may be more than a nuisance. Untreated snoring can increase your risk of diabetes, high blood pressure, heart failure and stroke. In children, snoring may increase the risk of attention-deficit/hyperactivity disorder (ADHD).
treatment of snoring

If losing weight and changing sleep position don't help, your physician or dentist may suggest

• Surgery to remove excess tissue in the back of the throat
• Laser surgery to remove some excess tissue from the uvula and soft palate
• Somnoplasty - a radio frequency signal used to reduce volume of tissues in the soft palate or tongue
• Strips implanted in the soft palate to stiffen it
• CPAP - this is positive air pressure applied through a pressurized mask over the nose.
• Oral appliance therapy - Dental appliances are specially constructed appliances much like a sports guard or some orthodontic appliances that will either hold the tongue forward or advance the lower jaw forward to open the airway in the back of your throat.

What you can do for yourself

To prevent or lessen snoring, try this:

• Lose weight if you are overweight - Being overweight is the most likely cause of snoring.
• Sleep on your side not on your back. Sewing a tennis ball in the back of a t-shirt can remind you not to sleep on your back.
• See a physician if you have chronic nasal congestion or obstruction
• Avoid drinking alcohol before you go to bed - Alcohol and sedatives can relax the muscles in the back of the throat and lead to snoring. In addition, they can increase the duration of apneic events by dulling your brain's activity that signals you to awaken and restart to breathe.

Snoring & Sleep Apnea

Normal Breathing

When you breathe normally, air passes through the nose and past the flexible structures in the back of the throat such as the soft palate, uvula and tongue. While you are awake, muscles hold the airway open. When you fall asleep, these muscles relax but, normally, the airway stays open

Snoring

Snoring is the sound of obstructed breathing during sleep. While snoring can be harmless(benign snoring), it can also be the sign of a more serious medical condition which progresses from upper airway resistance syndrome (UARS) to obstructive sleep apnea (OSA).

What causes snoring?

Snoring occurs when the structures in the throat are large and when the muscles relax enough to cause the airway to narrow and partially obstruct the flow of air. As air tries to passes through these obstructions, the throat structures vibrate causing the sound we know as snoring. Large tonsils, a long soft palate and uvula and excess fat deposits contribute to soft tissue narrowing.

Obstructive Sleep Apnea

When obstructive sleep apnea occurs, the tongue is sucked against the back of the throat. This blocks the upper airway and air flow stops. When the oxygen level in the brain becomes low enough, the sleeper partially awakens, the obstruction in the throat clears and the flow of air starts again, usually with a loud gasp. People with obstructive sleep apnea (OSA) have disrupted sleep, and low blood oxygen levels. OSA has been associated with cardiovascular problems and excessive daytime sleepiness. The condition known as upper airway resistance syndrome (UARS) lies midway between benign snoring and true obstructive sleep apnea. People with UARS suffer many of the symptoms of OSA but normal sleep testing will be negative.

How do you know if you have OSA?

Take a simple test but be sure to visit your physician if you think you have a problem. This test is for daytime sleepiness not specifically for snoring and apnea.  If you score high on the test be sure to visit your physician or dentist.

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with your personal physician.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze or sleep.
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping

Print out this test, fill in your answers and see where you stand.

Questionnaire for Sleep Apnea Risk

Assess your risk for sleep apnea. The total score for all 5 sections is your Apnea Risk Score. Print out this questionnaire, write in your best answer for each question and see where you stand.

1. How frequently do you experience or have you been told about snoring loud enough to disturb the sleep of others?
   
   1. Never
   2. Rarely (less than once a week)
   3. Occasionally (1 - 3 times a week)
   4. Frequently (More than 3 times a week)
      
      Answer: ____________
      
      
2. How often have you been told that you have "pauses" in breathing or stop breathing during sleep?
   
   
   1. Never
   2. Rarely (less than once a week)
   3. Occasionally (1 - 3 times a week)
   4. Frequently (More than 3 times a week)
      
      Answer: _______
      
      
3. How much are you overweight?
   
   1. Not at all
   2. Slightly (10 - 20 pounds)
   3. Moderately (20 - 40 pounds)
   4. Severely (More than 40 pounds)
      
      Answer: ________
      
      
4. What is your Epworth Sleepiness Score?
1. Less than 8
2. 9 -13
3. 14 - 18
4. 19 or greater
   
   Answer: ________
   
   
5. Does your medical history include:
   
   
   1. High blood pressure
   2. Stroke
   3. Heart disease
   4. More than 3 awakenings per night (on the average)
   5. Excessive fatigue
   6. Difficulty concentrating or staying awake during the day
      
      Answer: ________
      
      

If you answered 3) or 4) for questions A-D, especially if you have one or more of the conditions listed in question E, then you may be at risk for sleep apnea and should discuss this with your physician.

Note: You should always discuss sleep-related complaints with your physician before deciding on medical evaluation and treatment.

All About Fatigue: The Causes and Effects

(Reprinted with permission)

What is Fatigue:

• Fatigue is also known as sleepiness, tiredness, or exhaustion, and is a feeling of lack of energy or wanting to sleep.
• A number of medical conditions might cause fatigue but the most common cause is insufficient, high quality sleep (i.e., sleeping uninterrupted the entire time you’re in bed).
• When sufficiently fatigued, a person may experience very short, unremembered instances of sleep, called micro-sleeps, which can contribute to accidents.

Fatigue Impacts 40 million Americans with Sleep Disorders and Inadequate Sleep Causing:

• Increased health risks: high blood pressure, heart disease, stroke, and diabetes;
• Lack of energy to exercise and resulting weight gain;
• Sexual dysfunction;
• Mood swings, depression & irritability;
• Stresses on family & social life.

Consequences of Fatigue in the Workplace Includes:

• Impaired alertness & memory, inability to concentrate;
• Impaired judgment & poor decision making;
• Decreased motivation & productivity;
• Increased absenteeism;
• Increases by 3 to 5 time the likelihood of an accident.

Self-Management of Fatigue Is Important for Holders of Commercial Driver’s License (CDL):

• Being well rested is a requirement for being fit for duty.
• The hours-of-work requirement does not eliminate the driver’s responsibility for getting their needed hours of sleep or being treated so they are fully-rested while driving.
• If you drive while fatigued it is similar to having a blood alcohol content of .06 - .08. Nine out of 10 police officers have stopped a driver who they believed was drunk, but was later determined to be drowsy.
• Studies have shown that as many as 40% of commercial drivers have an undiagnosed sleep disorder that causes fatigue.
• It is the CDL holder’s responsibility to seek medical attention to ensure they do not have a sleep disorder or to obtain proper treatment.

Vulnerability to Fatigue:

• You are most vulnerable to fatigue when driving between 2 and 4 PM or 3 and 6 AM.
• The largest percentage of fatigue related accidents occur when a person is within 5 miles of their home or destination, when the brain’s drive to keep you awake begins to relax.
• The ability to perform adequately when fatigued is highly dependent on the individual. Some people need more hours of sleep to be fully rested. Others may become impaired sooner as a result of a lack of sleep.

Contributors to Poor Quality Sleep that Result in Fatigue:

• Having difficulty falling asleep can be influenced by factors that are difficult to control include:
  • Trying to sleep when the sun is up;
  • Falling asleep when you’re on a rotating schedule and the time that you go to bed keeps changing.
• Factors that make it difficult to fall asleep that you should try to avoid include:
  • Noise or interruptions;
  • Excessive stimulation prior to bed, such as an argument, physical exercise or eating;
  • Watching TV, using a computer, eating or reading/working while in bed. You want to avoid creating an association between activities that do not relate to sleeping while in bed.

Sleep Disorders that Contribute to Fatigue:

• Insomnia – can’t fall asleep, approximately 30 mm Americans affected, generally affects women more than men. Many of the environmental and behavioral/emotional conditions which affect high quality sleep contribute to the diagnosis of insomnia.
• Obstructive sleep apnea (OSA) – can’t breathe properly during sleep. Approximately 1 out of 5 men (20%( over age 40 have some degree of OSA, especially those who snore, are overweight or have large neck sizes. Among commercial drivers, the likelihood of having undiagnosed sleep apnea two times greater than the general male population. The severity of OSA ranges from 5 occurrences per hour to over 100. Each time an event occurs, the sleep is interrupted. OSA causes hypertension and if untreated reduces life expectancy by 10 years. 95% of those suffering from OSA are undiagnosed. Several treatment options exist. OSA is associated with lifelong diseases like diabetes or high blood pressure that should be diagnosed and treated for a driver to be “fit for duty”.
• Periodic limb movements in sleep (PLMS) – a less common disorder than OSA, often referred to as restless leg syndrome because the person needs to move their legs to be comfortable, but each time the legs move the sleep is interrupted. Not usually reported and diagnosed, a drug treatment is available.
• Narcolepsy – a rare disorder when a person will fall asleep in any place at any time. Is easily recognized and diagnosed, must be treated with a drug.

CDL Requirements for Diagnosis and Treatment of Obstructive Sleep Apnea (OSA):

• Department of Transportation guidelines require drivers with moderate to severe OSA to be treated in order to be fit for duty.
• You must disclose at the time of your DOT physical if you have been told that you snore loudly, or if you have awakened gasping for air or choking, or have been told you stop breathing, or are fatigued because these symptoms indicate you may have OSA. To avoid delays in being recertified, you should seek medical attention to determine if you have OSA and to receive treatment. Legal Implications of Driving while Fatigued:
• If you knowingly continue to drive when you’re fatigued or drowsy and have a collision, you will likely be liable for the injuries and damages caused to others.
• If you have a collision you could lose your CDL, and in the worst case be charged with vehicular manslaughter if you kill another person and it is shown that prior to the accident you:
  • Continued to drive while fatigued (even if there is a medical reason for the fatigue).
  • Did not seek medical attention to try and resolve the fatigue.
  • Did not report your fatigue at the time of your DOT physical.
  • Provided inaccurate or misleading responses to questions intended to determine if you have fatigue

© Advanced Brain Monitoring, Inc. 2007

Therapy (More about oral appliances)

There are several ways to treat snoring and sleep apnea. The most common is with a device called a CPAP machine. CPAP stands for continuous positive air pressure. It is usually applied through a tube to a mask that covers the nose. The air pressure that is generated splints the structures in the back of the throat holding the airway open during sleep.

Treatment can also be accomplished with surgery to the soft palate, uvula (that thing that hangs down from the roof of your mouth), and tongue to eliminate the tissue that collapses during sleep. More complex surgery can reposition the anatomic structure of your mouth and facial bones but this is done only in extreme cases.

Oral appliances that treat snoring and obstructive sleep apnea are small plastic devices, worn in the mouth, similar to orthodontic retainers or sports mouthguards. Oral appliance therapy involves the selection, design, fitting and use of a specially designed oral appliance that, when worn during sleep, maintains an opened, unobstructed airway in the throat.

Currently, there are over 40 different types of oral appliance available. Oral appliances may be used alone or in combination with other means of treating OSA, including general health and weight management, surgery or nasal continuous air pressure (CPAP).

Oral appliances work in several ways:

• By repositioning the lower jaw, tongue, soft palate and uvula
• By stabilizing the lower jaw and tongue
• By increasing the muscle tone of the tongue

Dentists with training in oral appliance therapy who are familiar with the various types and designs of appliances can determine which one is best suited for your specific dental and medical conditions. The dentist will work with your physician as part of the medical team in your diagnosis, treatment and on-going care. Oral appliance therapy can take from several weeks to several months to complete. Even after the intial phase of treatment is complete, your dentist will continue to follow you to be sure that treatment remains successful and to evaluate the response of your teeth and jaws.