Your Role in Dental Sleep Medicine P3

Dec
2013
22

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So, in our practice, if we had an average of patient roll of 2,000, 20% of the population has obstructive sleep apnea, and 80% to 90% are undiagnosed.  It’s really because the physicians don’t have time to look for it, and they really have very little training just because in medical school they’re covering so much more.  Maybe it’s half a day.  Maybe it’s three hours of lecture in medical school that talks about sleep apnea.

Now, with that many undiagnosed, there’s even more people who have been diagnosed and are untreated.  They’re not using their CPAP, they just couldn’t tolerate it, or they did surgery and it didn’t quite work.  So, a lot of dentists make snore-guards.  There were a million snore-guards manufactured last year, and that can be a dangerous territory if we don’t have a baseline.  If we make someone quite but they’re still having apnic events, we don’t know it because there’s no follow-through.  So, we really need to make sure that we get diagnosis first or screening and make a snore-guard for someone when they only, truly are snoring.

We are in the front lines, and the reason why I say that is because we are.  We spend more time with our patients.  We know them.  We know their wives.  We know their kids.  We sometimes spend more than an hour with them, and we look at airways all day long, and I really trained my staff and my hygienists to look at these things, too.  In fact, just before I went on this webinar, they knocked on my door to see if I could do a sleep apnea consult.  So, it’s everywhere you look.

Now, this is a patient that I’ve seen from day one in my practice.  I’ve been practicing for about 10 years, and I love it when Richard comes in.  We like to two-step down the hallway.  I’ve been bugging him for years.  Once I got my training, he was one of the first people that popped into my head as having a red flag for sleep apnea, but he was a little bit unwilling to hear it.  He said he has other problems.  He has high blood pressure and diabetes, and he’s tired all the time.  He’s been talking with a nasal voice.  This is actually really a good picture of him because he has lost weight since he’s been treated.

I finally got him to a point where he was willing to talk to a sleep physician.  He told me he was tired of being tired, and he went to talk to him.  I said, “You may not be a candidate for oral appliance, but we want you to get help.”  He went to the sleep physician.  He had a CPAP put on the night of his sleep test, and he was been sleeping wonderful ever since.  I actually get gifts from him every time I see him.

Now, Shawn, I’ve been treating his daughters and his family forever, and Shawn doesn’t fit that profile.  Remember, it says obese, elderly.  He is male.  He’s 45 years old even though he has gray hair.  He’s a pharmaceutical rep, and he saw my sign out in the waiting room about snoring.  He said, “You know, I started to have to sleep in the other room, and I noticed that every time I get on the plane, I fall asleep right away.  I didn’t use to do that.”  He thought it was because he was just getting old, and when I looked in his mouth, I saw a lot of the things that went unnoticed before when I wasn’t trained to look for it.

We got him tested.  He was actually able to do a home sleep test because he didn’t have a lot of the other sleep issues going on, and he had moderate sleep apnea.  We treated him with an oral appliance, and he takes it with him when he travels.  He doesn’t have to carry that CPAP machine, and he feels awesome.  His wife, of course, is the happiest camper of them all.

So, I do some external marketing as well as working with the physicians, and one day, Cindy saw my ad in the paper.  She came because she had a lot of insomnia, and her physician was treating her.  She had been treated for insomnia with a sleeping aid and depression with an antidepressant.  She is actually a RN that works in our Pan Handle district so she knows a little bit about health, and she came because she doesn’t snore.  She has to sleep in a recliner because every time she goes to sleep, she gets a panic attack.  Of course, her doctor wanted to give her a Valium® for that.

Come to find out, it was her airway narrowing and her body’s way of treating or trying to open up that airway.  She would get these panicky type feelings.  So, she has been for a year only two nights without her appliance, and that same feeling came back.  So, she can’t live without it.

Now, when we’re screening patients, some doctors have come up with different screening tools, one of them being STOP-BANG.  The anesthesiologists use this prior to surgery so when they’re putting a patient under and their airway’s relaxed, they can identify people they may have problems with.  The S stands for snore, and the T is for tired.  Are you tired during your day?  O, obstruction.  Have you noticed yourself stopped breathing, or has your spouse or anyone noticed you stopped breathing?  Do you have high blood pressure?  If you answered two out of four on the top part, you have a really high correlation to having sleep apnea.

On the second part, depending on how many you answer positive to, you have a chance for having sleep apnea.  In the BANG part, B is BMI.  A is age.  N is neck, and G is gender.  This is something really important to put in our history.  I know dentists that add that to their paperwork to screen virtually every patient.

This is the Epworth Sleepiness Scale.  This is the standard scale used.  There’s probably 10 out there, but these are the two most common ones.  Now, this tests how sleepy you are in certain situations.  Now, if you answer eight or more, that usually means that you are overtired.  I think I actually have a 17.  I haven’t seen the end of a rented movie in probably five years.  I just think it’s because I get up too early, but when a patient complains of being tired and they only have a score of 6 or 7, it’s worth going through the questionnaire with them because we did have a patient one time.  She was so tired, and that’s what she was complaining about.  When I went through it, she was like, “Well, I don’t own a TV.”  So, she had put a 0 there.  So, for some of these questions, you do need to discuss with the patient to get a better idea.

So, when we’re looking at a patient, as far as dentists being in the front line, we have their health history.  We have their medication lists.  We take their blood pressure.  There’s so many things that we do to help treat the whole patient, and there’s a lot of clues in the mouth, one of them being a large tongue.  Now, this is Otis, and he actually has an AHI of 86.  He was referred to me because no matter how hard he tried he couldn’t keep a sleep app on.  He said he put it on, and the next thing he knew it was off on the side of the bed.

With his tongue, you can see that it’s folder in the middle.  He doesn’t have enough space for the amount of room allowed.  You can see he’s not overweight too bad.  He’s normal looking, but there’s enough anatomical structures that were causing an obstruction.  Scalloped tongue.  We see these quite often, too, especially when you’re trying to do a crown on number two, and the tongue still gets in the way.  That’s another good indication that they may have an obstruction.  Scalloped tongue tells us that there’s too much tongue than the room allowed.  Again, it actually causes indentations.  So, you can see different degrees of that.

This is Otis’s throat, and you can see how beat up that uvula is.  So, it’s no wonder he has sleep apnea.  His tonsils aren’t big, but his uvula is a battered uvula as it’s that swollen.  In addition, his pharyngeal grade is also high, too, and that’s the width of that airway there.  You can see the pillars or the walls encroach upon that airway.

Now, this is a good indication.  When my husband and I play “Who Has Sleep Apnea?” in the airport, this is one of the telltale signs.  This is Cindy on the right that I told you about.  She has an inferiorly placed hyoid bone, and this is what we should look like.  That is a nice crico-hyoid space.

Overbite.  Overbite tells us that the mandible is pushed back, that it’s trapped back there.  Along with the mandible is the attachment to the tongue in the throat.  So, if the mandible is held back, so are those muscles and the airway.

Acid reflux. I know acid reflux doesn’t always present heartburn.  A lot of times we can question the patients.  A lot of times you’ve seen those areas that are eroded, and this is a pretty severe example here.  I think, as dentists, we can see it first.  When we ask the patients about it, it could be the acidic food that they eat. I know in the Pacific Northwest, we have a lot of fruit and smoothie drinkers and health nuts.  So, I do see this front tooth, but when I question patients about it, they, “No, I’m fine.  I don’t have heartburn.”

It doesn’t always show up as heartburn. I was diagnosed with it after I had chronic cough for two months.  Anytime I went out in the cold or if I exercised, I would cough and cough and cough because the acid had affected the vocal chords and irritated them.  In addition, you can have constant clearing of the throat.  If you know someone that has that or they say they have allergies all year long in that post-nasal drip, it begs a question to ask about acid reflux.  One way to test it is to do Prilosec OTC® once a day, and if it helps their post-nasal drip, then, that’s a clue that it was acid reflux.

Again, I talked to you about bruxing, and that’s a sign.  That’s a way our brain tells us to kick start our breathing again.  There’s severe cases where we see this every day, and by doing a night-guard, you are actually crowding that space, crowding the tongue.  So, that’s a question to ask before you make a night-guard for someone.  Do they have other signs and symptoms such as if they are possibly snoring or possibly have sleep apnea?

Clenching.  It’s a way for our body to posture that mandible forward and open up the airway and pull that tongue forward.  Mouth-breathing.  This is common, and we, as dentists, see it because the patient’s gingiva is all red and their mouth is hanging open.  The plaque just dries on the front teeth.  We see it a lot on kids.  Sometimes they outgrow it.  Sometimes they don’t, but that tongue pressure is important to form the palate.  So, early intervention in kids is important.  We don’t treat them all the time with CPAP.  Most of the time, it’s getting their tonsils out and adenoids out and expanding the palate is a good way to prevent them from being adult apnics.  Of course, we see it in adults, too.

With a vaulted palate, it tells us that as a kid, they didn’t breathe right.  Maybe they breathe right now, but if you think about a vaulted palate, it actually pinches on the nasal component.  So, it narrows that passageway even more.  This is a patient of mine.  You can’t get a good appreciation for how high his palate really is in this picture. If you notice, growing up he couldn’t afford braces so if you notice, in order to prevent that crowding, they pulled the premolars to try to help these teeth into that.  If you pull the premolars right into the space where they’re actually growing the most, you actually prevent the mandible from growing forward, too.  That’s another way that crowds the airway.

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