Your Role in Dental Sleep Medicine P2

Dec
2013
15

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Now, hyperapnia, if you remember, is a buildup of CO2, and CO2 is actually what causes our brain to breathe.  It’s the reaction our brain has to CO2 rather than oxygen that tells our body to breathe.  So, once we realize that, our brain sends an activator, a little squirt of adrenaline.  That is the smooth muscle contractor that gets the airway open again.  So, we can grab a few breaths, relax again, and go to sleep.  Then, the whole system starts over again, and you wonder why we’re tired.

This is a video of a man having an apnic event.  As you can see, he’s trying to breathe, trying to breathe.  He’s quite because he has an obstruction in airflow, and he still continues to try to breathe.  You can do it, buddy.  Now, I guarantee you, if you try to do that even being awake, it would be difficult to hold your breath that long.

It’s like holding your breath at the bottom of the swimming pool. Your body’s going to do anything to try to get the air.  So, sometimes we gasp or our legs kick or we grind our teeth together, whatever it takes to get that diaphragm moving again, and it’s almost worse than holding your breath underwater because if you see, he started getting the obstruction right at the end of the breath, at the end of the expiration.  So, it’s like trying to release all the air out of your lungs and then holding your breath for that long.  You can see why most people don’t wake up refreshed.

The typical signs and symptoms of obstructive sleep apnea are of course obesity.  We have a huge obesity problem in America, and we see the census every year changing.  We have more categories of obesity, which is really scary for our health care.  Then, with snoring, that is basically pre-empting it.  That is usually the chief complaint that brings people in.  Most of the time when people come in for a consult it’s because their wife or husband forced them, and a lot of times it isn’t the daytime sleepiness.  The chief complaint is snoring.

In fragmented or light sleep, a lot of people say they have a lot of trouble sleeping or say they have insomnias.  A lot of times it can be related to sleep apnea, and the most tell-tale sign really is when a wife or husband tells us that they have to nudge their spouses again to start breathing, that they get scared something’s going to happen to them when they sleep.

Again, our memory and learning take place during REM sleep, and if we never reach that, we’re going to have poor memory, morning headaches from oxygen depletion.  A lot of time when people complain to us about headaches, we think TMJ.  It kind of begs the question to ask them about their sleep, and, of course, if someone’s grumpy, their family’s not going to like being around them.

The nocturnal enuresis is basically the safety word for getting up and using the restroom often in the night.  The reason I included that is I never realized how common it was until I started talking to my patients about it.  We actually treated my hygienist’s husband. She tells me all the time how much lower their water bill is because he always thought he had a bad prostate and had to get up four or five times a night, but he little squirt of adrenaline that your pituitary gland allows the release of actually can get our bladder moving, too.

So, why do we want to treat it?  Like Dr. Lavine said, there’s a lot of health consequences, and, especially as dentists, we are a lot more than just people who cut on enamel rods. With treating perio, we see that there’s a link between the oral cavity and the whole body.  So, we see 80% of nocturnal stroke victims have untreated obstructive sleep apnea.  Heart attacks.  You have a 30% higher chance of having a heart attack.  Dementia.  When they tested people in the Alzheimer’s Board, they found out that 90% of them had untreated obstructive sleep apnea. Acid reflux.

Hypertension, especially with patients whose hypertension is not controlled even with medication, 83% of the patients have obstructive sleep apnea.  Cancer.  I should you that new release, that study that they’re three times more likely to die, and, of course, it’s related to obesity.  I think that’s a vicious cycle because when you’re tired and not feeling good, you’re not going to want to get up and go to the gym.  In addition, the sleep cycle is where those appetite suppressant hormones are released and our hunger hormones are released.  So, if we’re not getting the proper regulation, I just don’t think that we’re motivated to eat right.

Diabetes.  Again, sleep is when those hormones a regulated.  You’re two and a half times more likely to have diabetes if you have obstructive sleep apnea.  With auto accidents, drowsy drivers are just as dangerous as drunk drivers.  In fact, they found that the crashes that drowsy drivers get in are five times more serious and more fatal.

Of course, if we’re not sleeping, we’re not doing good, and the only reason why I included this one is even my six year old knows that Cialis® is for daily use.  I think that I don’t talk to my patients a lot of about this and they don’t really admit it, but it has a huge effect.  The lack of oxygen in our bodies have a huge effect on this area. It’s something that we don’t talk about, but it’s obviously out there because I hear a commercial or see a commercial probably five times a day.

Death. This is Reggie White.  His wife is actually a spokesperson for sleep apnea now, trying to get low income people get diagnosed as well as treated.  If you remember, he died in his sleep.  They never say that a patient died from sleep apnea.  It’s usually heart failure or natural causes, but dying at 50 of heart failure is not really natural in my opinion.  Sleep is where we’re supposed to be resting, not dying.

So, how do we get diagnosed?  That’s the first step.  It must be made by a sleep physician, and we do that by getting a sleep study.  The most common is PSG or polysomnograph in which you go to a sleep lab, and they’re actually really comfortable.  I have one that is in a hospital and one that is a sleep lab.  It’s a little bit like a hotel.  You have TV and the amenities at home, and you’re allowed to bring your own pillow.

This is what we do.  There’s a lot of wires, but they test for a lot of things.  There are wires to your heart for ECG and wires attached to your head for REM, which is rapid eye movement.  Brain waves as well as channels on your chin to test for bruxing as well as on your legs to test for restless leg syndrome or periodic limb movements, which are leg kicks, which are common with apnea as well.  Then, of course, there are nasal flow, pulse oxygen. They can test more than just sleep apnea because there are many sleep disorders.

It is technician-assisted.  This is actually my dental sleep coordinator right here.  She makes the best coordinator because she actually has sleep apnea herself and really can’t sleep without her oral implants.  So, she is great with the patients and really advises them.  So, the technician sets it up, and, in my opinion, it’s a nice night away from home.  I actually had one as well, and I thought, “This is great, and my husband’s not pestering me to move around.”

Then, they print out a report. I know this looks confusing and it looks like a bunch of squiggles, but when you enter dental sleep medicine world, you’ll see that you’ll be able to see what this means and interpret it for your patients.  This is a typical sleep apnea patient.  Here is his chin movement.  So, bruxing can be associated with obstructive sleep apnea as well.

In addition, there are home sleep tests that are becoming more and more common because more patients aren’t wanting to go to a sleep lab.  They’re more resistant to seeking treatment.  More and more physicians are open to home sleep testing.  In addition, if there are no other co-morbidities and no other sleep disorders, obstructive sleep apnea is what they have, then, the physicians can do a home sleep study.

This is one type.  The type IV just means that there are two channels that are measured, and I’ll talk about that in a moment.  Type II is basically a PSG at home.  There is no technician, but there’s still those leads and wires.  Type III is what you see here.  There’s a respiratory valve as well as a reader and nasal canula to study oxygen flow.  This is another type where he just wears it on the head, and it can test position, airflow, pulse, and the oxygen saturation.  It does rely on the patient’s place, and sometimes, they can’t get it right.  I know my in-laws were visiting, and they did a home sleep test.  I had explained it to them but still had to help them.

Okay, this is the type IV I was talking about, and only two channels are read.  Patients, when I ask them if they snore or if they possibly have sleep apnea, I can see a lot of the signs, they say, “Oh, I was tested, and I don’t have it.” Well, I asked them what kind of test they had, and usually, they said they wore something on their finger.  It’s really common for primary care physicians to send their patient home with this just to test them, but it’s not really going to show you if you have mild or moderate sleep apnea.  It’s mostly if you have severe desaturations during your sleep.  So, it’s really going to show you severe sleep apnea but not the mild and moderate.  So, I don’t really consider it a good screening tool, but a lot of physicians use it because it’s cheap and easy.

Now, when you talk to physicians, we’re entering their world.  It’s dental sleep medicine so we have to put on our doctor hats for a little bit, and in doing that, we talked in AHI.  That’s how you determine how severe or mild someone’s sleep apnea is, and that stands for apnea-hypopnea index.   The apnea-hypopnea index is where you take the amount of apneas, where there stop breathing for 10 seconds or more, and add in the hypopneas, where there is the narrowing of the airway and their oxygen desaturates by 4%.  Then, you divide it by the amount of hours slept.  So, that gives us a number and a scale so that we can now how bad somebody is.  I’ve had a patient as high as 128, and he was a [26:04].  So, that was pretty severe.

Now, the RDI.  That’s another thing that people will talk about, and that’s the respiratory disturbance index.  That’s where they add in the RERAs.  RERAs stands for respiratory effort related arousal in which you are aroused to a higher stage of sleep, but there is no oxygen desaturation.  So, sleep cycle’s still getting disturbed and interrupted.  I had a patient who had an AHI of 7 but an RDI of 20.  They were very tire.  So, we were able to get medical insurance to cover them.  Now, typically, this is what doctors will see.  Someone who’s overweight, old, male, and has a large, thick neck, those are the ones that usually get diagnosed, but there are many who go undiagnosed.

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