Your Role in Dental Sleep Medicine P4
2013
It’s amazing to see in the petite women I see how many have had their premolars removed. If their petite women, usually their airway’s petite, too. This are his lower teeth, and you can see how V-shaped that is. If you notice, too, this is him open. His tongue falls right back.
Gag reflex. That’s our body’s way of keeping obstructions out of our throat. I have a couple of patients that are actually treated with CPAP, but every time I see their name on the schedule and I see x-rays, I say a little prayer for my hygienist because it’s really tough for them to get through that. Anytime I see a gagger, it raises a red flag. It’s not saying that they definitely have it, or they are diagnosed with it or anything. It’s just that all these clues can tell us something, and, again, we’re looking at airways all the time.
This is a nice airway. This is something we can see in adult patients as well as kid patients. Now, in our kid patients, when we I talk to the parents, I’ll talk to them about if they are 6 or 7 and still wetting the bed, if they have bags under their eyes, they’re called shiners. They fall asleep really easy because a lot of kids that are sleep deprived fall asleep really easy, but I’ll ask them, “Do they have restless sleep? Do they move around a lot? Are the sheets crumpled up in the bottom of the bed in the morning?” That’s telling me that they sleep about 8 or 9 hours, but they’re not getting good sleep. Because kids’ nervous systems are not matured yet, it’s like when I give my two kids Benadryl®. One gets higher and one gets real drowsy.
Because the nervous system isn’t really developed yet, when kids get tired, they can get wired. So, they are finding that ADD and ADHD are related to sleep. Again, in kids, the first thing we look at is airway. When I ask the parents to talk to their pediatricians, I tell them that we’re not looking at sore throats. We’re looking at the fact that they can’t breathe through their nose, and it’s affecting their sleep.
So, it’s really important when we talk about treatment options that there are more things than just CPAP or oral appliances. Sleep hygiene is really easy. That’s something to coach your patients on, going to bed at a normal time, getting up at a normal time. If they’re shift workers, try to keep them on that same schedule, keeping electronics out of the bedroom, keeping TVs out of the bedroom. If you do wake up, don’t go watch TV or get into your computer. Just do some nice quiet reading. These are all things that help get good quality sleep so we are well-rested in the morning.
We need 7.7 hours and 40% of the American population gets 5 hours or less. In addition, the use of electronics and video games has caused a lot of us to be night owls. I still go to bed at 9. In addition, if you are having trouble sleeping, going to sleep in a quiet room, dark room, even a little bit of light can affect our sleep and Circadian rhythm and melatonin release. One way to stimulate melatonin is to take a hot bath and get into a cold bed.
Lifestyle modifications. That includes exercising regularly but not too close to bedtime, no smoking, no alcohol. Alcohol actually relaxes the soft tissue so much that it can cause even more crowding of the airway, and some people even say they snore only when they drink. That’s because it relaxes the smooth muscle of the throat.
Positional therapy. Some patients only have closing off or obstruction when they’re on their back. So, keeping them on their side would be a good solution. The problem is getting patients to actually do it. We coach patients on it all the time, but they rarely follow through. One strategy is to install [45:29] on the back of their t-shirt and keep them off their back. I know a Canadian that actually use hockey puck and places them on a hose and places them right on his kidney. A bed wedge is really easy to use and successful. It’s really easy to use. It’s just a foam, wedge that you can place under your mattress to keep it on a slope so that you can sleep on your side.
Of course, we have surgery. It’s really important to have an ENT that you can work with, an oral surgeon that you can work with that get it. Again, with the children, we’re not looking for sore throat, strep throat. I want tonsils or adenoids out if it’s causing airway obstruction, and having an ENT that works with you is great. A lot of times, they want to work with you, too. They want somewhere to send their patients who aren’t surgical candidates. Of course, we have CPAP and oral appliances.
We’re going to get into surgery in a little bit here. Nasal obstructions. There’s a couple of ways to treat that. This is a deviated septum as well as a big turbine, and you can actually get these fixed and allow you to breathe through your nose again. This is radiofrequency, energy that is delivered beneath the surface of the turbine. The treated tissue is heated to coagulate, and over the next three to six weeks, the tissue shrinks.
So, a lot of times, we’re hesitant to send our patients for surgery, but there are some in-office procedures that can be done to help, especially since oral appliances don’t always affect the nasal area. We do need to sometimes treat that area as well.
There’s tonsillectomy. This is a common procedure. It’s not so common anymore because what we’re realizing is that obstructions aren’t in the soft palate and uvula area. This is most commonly referred to as UPPP. We don’t use uvupalatopharyngoplasty. This is a patient that just came in a few weeks ago. This is post-surgery, but with this patient here, you can see quite a bit of his soft palate and uvula are gone. In fact, he does have trouble swallowing in that area now. So, he said that he’s cured of sleep apnea. I said, “What does your follow-up sleep study say.” He said, “Oh, I never had one.” He figured since he doesn’t snore anymore, he’s fine, but every time he comes in, he falls asleep on my chair. So, I said, “Well, let’s just do a screening for you. Let’s work with someone so we can just see what’s going on.” He ended up having an AHI of 43, and he said he was cured. So, it doesn’t always work.
A tongue resection and hyoid suspension is another common procedure, and it’s where they place a screw in the mandible attached to sutures and wrapped around the myeloid bone to stabilize it. It doesn’t always pull the muscles tight, but it helps prevent the collapse during the sleep at night. A tongue resection, of course, is you’re just taking out a section of the tongue, too.
This is a patient of mine that was actually getting treated by a dentist in Seattle when she moved here, and she had an oral appliance. She extracted a few of the teeth that I had worked on, and I was upset by it. So, I sent her to an orthodontist, and he basically sent her back to me and said, “Breathing at night is more important than a few shifted teeth.” That’s when I finally realized that I had to get out of my dental mentality and look at the patient and treat them as a medical patient.
So, she actually ended up going and getting a [48:27], and that’s where they take a block of bone right where the muscles of the tongue and throat attach, pull it out, twist it 90 degrees, and put it back in. Because she was petite, this worked out really well for her, and she did do a follow-up study.
Maxilomandibular advancement. This is the most successful treatment, usually works out 90% because we are taking the maxilla and mandible and moving it forward 10 millimeters. So, by doing that, you’re not only stabilizing the hyoid bone and all the muscles attached to it but also creating more space for that airway. You can see, it’s moving the nasal area forward, too. This is actually a local patient. Of course, the 100% solution is just to bypass the airway altogether.
Now, CPAP is continuous positive airway pressure. It doesn’t give the patient oxygen. It doesn’t supplement oxygen. It doesn’t make their blood richer and full of oxygen. It just flows enough air out to move the soft tissue out of the way. So, the more blockages there are, the higher the pressure’s going to be. I don’t know if you’ve ever tried one or tried one on, but it is a really weird experience. For patients who are really sick and really severe, it’s really easy for them to use because they feel so much better. It is a gold standard because it does work, but the compliance is really low. I’m glad you guys saw a better picture of me because this is what I took in my sleep study.
The compliance is low, but it is getting better. When I asked my local sleep physician where his compliance was, he told me it was high 80s, and then you see numbers in studies that say 40%. So, there’s a huge range, and there’s also a really liberal definition of what compliance is. A successfully treated patient is someone who wears a CPAP four nights a week and, of those nights, four hours a night. So, they say that’s enough treatment to get to lower their chance of co-morbidities, but in my opinion it seems like a really liberal definition because that is not a whole lot of sleep.
Most of the patients actually wear their appliance all night, and when I ask them about their use, they’re embarrassed to admit that they take it out at 5:30 in the morning and sleep until 6. I say, “That’s okay. I think you got some good treatment there.” It is getting better because they have different masks. Some of the chronic complaints are claustrophobia. “The mask leaks air into my eyes and causes irritation,” or it can cause irritation on the bridge of the nose or they take it off and they don’t know why. A lot of times they can work around that with dry mouths with the use of humidifiers. They do help. It does limit your sleep positions so that bugs a lot of people sometimes, but there are even masks now where you can sleep on your side.
Of course, the reason we’re all here now, where we fit into the piece of the puzzle, is by treating with oral appliances. So, we prevent the collapse but also improve the muscle tone, and it’s counter-intuitive because you think that by pulling that mandible forward, we’re opening up the airway in the anterior and posterior way, but the way the pharyngeal constrictors is that they open the airway laterally. In addition, by pulling that mandible forward, the pterygomandibular raphe, it tightens up the palatine aponeuroses, which is all the tissue of the soft palate, and by tightening that, you actually prevent the vibration and prevent the snoring.