The Sleep Apnea / Cardiovascular Connection

Sleep apnea is extremely common in patients with cardiovascular disease. It is well known that when sleep apnea is left untreated, medical comorbidities are likely including; cardiovascular complications such as hypertension, heart attack, stroke, A-Fib, and endothelial dysfunction. Understanding the relationship between these two serious maladies and how to impact the ongoing negative cycle by treating OSA can help your patients improve their cardiovascular health.

 

Blood Pressure During Sleep

Sleep should be a time when the body regenerates, and recovers from the stress of waking hours. In normal sleep and breathing, blood pressure and heart rate remain below waking levels on average. For individuals without sleep apnea, sleep and normal breathing has a relaxing effect on the cardiovascular system. However for sleep apnea sufferers, disrupted breathing has a negative effect on the cardiovascular system that may result in an increase in blood pressure, cardiac dysrhythmias, endothelial dysfunction and more. The mechanisms triggered by sleep-disordered breathing can carry over into waking hours.

 

Sleep Apnea and Hypertension

Intermittent desaturations at night are associated with release of stress hormones (catecholamines) that cause vasoconstriction and elevated blood pressure. Studies have shown that this elevation in catecholamine then persists during the daytime resulting in systemic hypertension.

Patients with sleep apnea are also at risk for cardiac rhythm disturbances especially ventricular arrhythmias and atrial fibrillation as well as myocardial ischemia.
Untreated Sleep Apnea can lead to hypertension, cardiac Arrhythmias, Stroke, Myocardial ischemiaIt is estimated that 80% of Americans with sleep apnea are undiagnosed. Sleep apnea affects more than 20 million unaware Americans. This is why we urge health care practitioners such as yourself to keep sleep health at the forefront during patient interaction. Treating sleep apnea in individuals who also have cardiovascular issues has been proven to improve co-morbidities like hypertension and arrhythmia.

 

Start with Sleep Health

When assessing your patients, it is useful to inquire about quality of sleep, presence of snoring, observed apneas, awakening from sleep gasping and daytime hypersomnolence.  Urge your patients to get a sleep test when appropriate, and begin managing sleep apnea if indicated.

Please use our website as a resource, both for yourself, and for your patients. We have many blog articles to help understand sleep apnea, treatment options, the effects of sleep deprivation, sleep study information, and more. Our goal is to help your patients get treated if they suffer from sleep apnea, and improve their quality of life starting with improving sleep health.

This blog was co-written by Dr. Rogers, DMD, DABDSM, and Dr. Bijwadia, MD.

For Endocrinologists: Recognizing and Addressing Obstructive Sleep Apnea will Benefit Your Patients

The last thing your diabetic patients need is another complication that increases their risk for comorbidity or further complications.Screen Shot 2015-11-23 at 5.30.21 PM

Untreated obstructive sleep apnea (OSA) can lead to serious consequences and further complications for your diabetic patients. OSA makes controlling blood sugar more difficult. In patients with obstructive sleep apnea repeated airway closure triggers a flight or fright response, which produces a high level of cortisol. Elevated levels of cortisol have been associated with insulin resistance and glucose intolerance. Frequent drops in oxygen levels causing stress at the cellular level also likely explain why blood sugars may be harder to control.
Other complications of the sleep disorder include:

  • Cardiovascular disease (hypertension, heart attack, stroke, A-Fib, endothelial dysfunction…)
  • Depression
  • Decreased libido
  • Neurocognitive deficit (daytime hypersomnolence, irritability, memory decrement, decreased productivity at work…)
  • Socially unacceptable snoring
  • Accidents and injury in the workplace and on the highwa

Diabetic patients are more likely to be overweight, which increases their likelihood of suffering from OSA. As a person gains weight, the excess fat accumulates in the soft tissues and neck potentially narrowing the airway. This is why the risk for sleep disordered breathing increases even more so with overweight and obese individuals.

So how can Endocrinologists such as yourself help?Screen Shot 2015-11-23 at 5.29.30 PM

A widely quoted British study reported 23% of type 2 diabetics have sleep apnea and more recent studies (such as the study results from ResMed cited below) have shown even higher numbers. The International Diabetes Federation Taskforce on Epidemiology and Prevention strongly recommends that health professionals working in both type 2 diabetes and SDB adopt clinical practices to ensure that a patient presenting with one condition is considered for the other.

It is estimated that 80% of Americans who suffer from sleep apnea remain undiagnosed. In order to combat this sleep condition that affects more than 20 million unaware Americans, health care practitioners such as yourself must remember to keep sleep health at the forefront during patient interaction.

This blog was co-written by Dr. Rogers, DMD, DABDSM, and Dr. Bijwadia, MD.

Primary Care Physicians: Recognizing and Addressing Obstructive Sleep Apnea will Benefit Your Patients

As you know, obstructive sleep apnea (OSA) can lead to serious comorbidity. When OSA goes untreated, your patients are at increased risk for:
• Cardiovascular disease (hypertension, heart attack, stroke, A-Fib, endothelial dysfunction…)
• Diabetes
• Depression
• Decreased libido
• Neurocognitive deficit (daytime hypersomnolence, irritability, memory decrement, decreased productivity at work…)
• Socially unacceptable snoring
• Accidents and injury in the workplace and on the highway

Sleep health should be kept at the forefront during all patient interaction.

Over 20 million Americans are unaware they have sleep apnea.

It is estimated that 22 million Americans suffer from obstructive sleep apnea, with 80 percent of cases undiagnosed. So 20 million Americans are living with a very serious sleep disorder and may not realize they need to be treated.

Treatment for OSA can start with you, the primary care physician. This blog is meant to serve as a reminder to keep sleep health at the forefront when consulting with your patients. It offers additional perspective when treating many maladies, oftentimes treating the root of the problem rather than merely symptoms or consequences. Screening for sleep apnea can start with a simple set of questions asking about symptoms listed below. If sleep apnea is suspected, a sleep test (in-home or in-lab) is easy to order and can accurately diagnose the problem.

Nighttime symptoms may include snoring, observed pauses in breathing or awakenings with a choking or gasping sensation. Daytime symptoms include excessive sleepiness, impaired alertness, irritability, difficulty concentrating and drowsiness behind the wheel. It is particularly helpful to note that sleep apnea occurs often times in our patients who are not overweight.

Sleep Apnea Research

Please use our website as a resource, both for yourself, and for your patients. We have many different blog articles to help your patients understand sleep apnea, treatment options, the effects of sleep deprivation, sleep study information, and more. Our goal is to help get treatment for those who need it, and improve their quality of life through better quality sleep.

We post our professional information on the Pittsburgh Dental Sleep Medicine LinkedIn page, and post Network news, oral appliance articles, sleep tips, and sleep apnea information our Facebook page. Take a moment to Like or Follow Us in either place to keep sleep apnea at the forefront of your patient discussions.

Pittsburgh Dental Sleep Medicine has been working with primary care physicians, sleep specialists and other medical specialists for over 25 years to treat patients who are either CPAP intolerant or reject CPAP as a treatment modality. The dentists in our network are board-certified in dental sleep medicine (or board eligible) and all of the offices are nationally accredited in dental sleep medicine.

 

This blog was co-written by Dr. Rogers, DMD, DABDSM, and Dr. Bijwadia, MD.

Big News from the American Board of Dental Sleep Medicine

A huge congratulations to Pittsburgh Dental Sleep Medicine’s very own, Dr. Michael Fazzini who very recently passed the Dental Sleep Medicine Board Certification Written Exam! What a major feat and outstanding achievement.

To become Board Certified, one must fulfill all of the following requirements from the American Board of Dental Sleep Medicine:

  • Licensed dentist
  • Completed at least 50 hours of continuing education in dental sleep medicine or sleep medicine
  • Recommended by at least two board-certified sleep physicians
  • Observed at least 10 hours of operations at an accredited sleep center with sleep medicine medical staff
  • Passed a rigorous written examination demonstrating competency in dental sleep medicine
  • Demonstrated competency in all phases of oral appliance therapy by presenting actual patient cases to a board of dental sleep medicine peers

We are all incredibly proud of Dr. Fazzini for his hard work and dedication to dental sleep medicine. Dr. Fazzini was kind enough to answer a few questions about himself, his interest in dental sleep medicine, and the what it took to get him where he is today, so close to becoming a diplomat of the American Board of Dental Sleep Medicine. Now that he has passed his exam, he has overcome the major hurdle in becoming qualified. Once the board approves Dr. Fazzini’s cases, he will have fully completed the process to becoming Board Certified in Dental Sleep Medicine. Learn more about Dr. Fazzini and get a glimpse of his sincerity, compassion, and ongoing capacity to learn through his comments below.

Dr. Michael Fazzini

1.) Why are you interested in Dental Sleep Medicine?

I became interested four years ago when my friend, Dr. Rob Rogers, asked me if I would like to shadow him a few days in his office. Rob had been treating sleep disorders exclusively in his practice for some years at that time. He told me then that he was interested in putting together a network of highly trained dentists who could offer care for people with sleep apnea and primary snoring. He thought I might be a good candidate to be one of those dentists. I was touched and honored by his confidence in me, enjoyed being a part of the difference his treatment made for others so I decided to give it a go.

2.) When did you become interested in Dental Sleep Medicine?

When I started I really knew very little but through his mentorship, training that took place at venues all over the country and a good deal of self study I became educated about sleep and the different ways sleep disorders are managed by physicians and dentists.

3.) Why was becoming Board Certified for Dental Sleep Medicine a goal of yours?

Very early on. Rob always intended that his associates would be recognized as leaders in the field. Becoming a diplomate of the American Board of Dental Sleep Medicine is the most widely recognized means within the medical and dental communities to communicate the idea, “this person has attained an exceptional level of knowledge, understanding and clinical skill to treat sleep disorders.”

4.) Why do you focus on Oral Appliances versus other treatment options like CPAP?

My focus is on oral appliance therapy because I am a dentist, it’s what we do. That being said, I have an appreciation for and good knowledge of the other forms of treatment for sleep apnea that are in common use today including CPAP. A broad understanding of what oral appliances can and cannot do is key in successful patient care. Not everyone who comes to us for treatment is a candidate for oral appliance therapy so knowing how to go forward with people when that is the case is also part of my training.

5.) Why do you like being a part of a network of Dental Sleep Medicine Practitioners?

For me professionally it provides a network of colleagues who are a reservoir of knowledge and clinical experience. We share successes and trials with each other regularly and benefit tremendously from the cumulative wisdom of the group. By extension our patients are the beneficiaries of these interactions.

6.) Briefly explain the process of becoming Board Certified.

 Becoming a diplomate of the American Board of Dental Sleep Medicine is a multi year process. It involves passing a multilayered challenge.

The first is documenting 15 cases that I have treated in the most comprehensive way, as specified by the Board, and presenting them as a portfolio to be judged. If this sounds easy, believe me when I tell you, it is not. The degree of detail required by the Board far exceeds everyday norms and demands special attention be paid to every part of the process. It is very demanding in its detail and scope. I am working on completing this phase and expect to be done with it by January 1, 2016.

The second requirement is passing a four hour exam testing the individual on all areas of sleep medicine, sleep disorders, pharmacology and treatment modalities. That is the exam I recently passed. Studying for the exam was about a 1-year process that happened in the evenings when I was done with my clinical practice. It was a grind but a necessary piece of putting together the whole package required to become a diplomate.

The final challenge is completing over 50 hours of specialized classroom work and spending many hours in sleep labs monitoring sleeping patients in order to become familiar with sleep testing and how they are used and graded.

 7.) How do you plan on continuing your education as a Board-Certified in Dental Sleep Medicine Doctor?

I am not quite complete yet but I can see the finish line. In the near term my efforts are being directed toward the successful completion of my portfolio. Going forward I will continue to pursue my education related to sleep disorders and work on being well informed as to the continuing improvements in treatments available to patients.

 8.) What do you look forward to in the future in regard to putting your certification and new education to use?

The whole purpose behind the training and the work is to be able to apply my knowledge to helping people suffering from sleep disorders. It has been very gratifying to know that there are people living more productive and happy lives because of what I do. It’s what gets me out of bed every morning looking forward to my day.

How Employers Can Benefit from Screening Employees for Sleep Apnea

Sleeping on the Job

Both businesses that operate heavy machinery and businesses that operate from offices can increase profits by screening employees for Obstructive Sleep Apnea (OSA).

If you own or run a company that operates machinery or has any risk of on-the-job injury, then OSA screening may decrease your risk of injury. On the opposite end of the work spectrum, untreated OSA can cause excessive daytime sleepiness, resulting in impaired cognitive function and decreased employee productivity. Most businesses live by the motto ‘decreased spending to increase profits’. Screening and treating workers for OSA can save any business, whether you own a construction company or an IT company, a substantial amount of money through higher productivity and less spending.

Decrease Occupational Injury

Researchers from the University of British Columbia, Vancouver, recently completed a study that used objective criteria to identify both occupational injuries and their relation to obstructive sleep apnea. The study was conducted to determine whether patients with sleep apnea were more at risk of occupational injury than the average person. The study is the largest of its kind, and tells us how sleep apnea affects real life tasks, people, and business. The study proved that people suffering from untreated OSA were nearly twice (95%) more likely to get hurt on the job than someone without OSA. We know that sleep apnea increases the risk of motor vehicle accidents, but now we have a large, reliable study to illustrate how OSA also affects us on the job by increasing occupational hazards. Read more about the study on MedPage Today.

Increase Employee Productivity

A study that compares excessive daytime sleepiness (EDS) and work performance in the general population among heavy snorers and patients with OSA found that snorers and OSA patients are exceedingly more likely to have EDS and consequently have decreased work performance. Snorers in the general population where 4 times more likely to experience EDS, and OSA patients were 40 times more likely. Learn more about the study on PubMed.

Asleep at Work

Untreated OSA in the General Workplace

Untreated obstructive sleep apnea impacts your workday by impairing cognitive functions including decision-making, mood and outlook, and more. Furthermore, having apneas and hypopneas throughout the night offset your sleep cycle thus making REM sleep occur less often or not at all. According to the National Sleep Foundation, REM sleep plays the following roles within the sleep stages:

  • Provides energy to brain and body
  • Supports daytime performance
  • Brain is active and dreams occur
  • Eyes dart back and forth
  • Body becomes immobile and relaxed, as muscles are turned off

REM sleep plays a role in creativity, learning, and memory. Inconveniently, REM sleep stage is the stage most disrupted by sleep apnea. The apneas or hypopneas experienced by untreated OSA also affect motor skills and processing speed due to the lower levels of blood oxygen they create. Sleep apnea impairs intellectual and executive functions affecting processes such as concentration, reaction, alertness, and more. Testing employees for OSA can help them and in turn help you with higher productivity on the job. Get the most out of your employees and help them live happier healthier lives with treatment for sleep apnea.

If you are worried about the cost of Sleep Apnea screening, learn more about our insurance coverage on the Pittsburgh Dental Sleep Medicine Insurance Coverage webpage, or give us a call at 724.935.6670 to find out if we accept your businesses insurance.

 

Perspective: Who is Qualified to Evaluate Sleep Apnea?

 

Dental Sleep Practice is the Sleep Apnea publication for dentists. Dr. Rogers of Pittsburgh Dental Sleep Medicine has been featured in their Fall 2014 issue with an article he wrote, titled “Perspective”.

‘This is a particularly exciting time to be involved in dental sleep medicine. We have, as they say, reached critical mass. To a meaningful extent we have shown that the concept of oral appliance therapy is legitimate and effective. Most physicians understand this. Most insurance companies recognize this. Many dentists are competent and treating patients effectively.” 

                                                                                                             -Dr. Rogers

He talks about the creation of the Academy of Sleep Medicine, the hard beginnings and the distance sleep apnea specialists have come, as well as the continuous struggle to figure out which direction the treatment of sleep apnea should be going, and the consequences of that direction. The article is most interesting for physicians and dentists, discussing the relationship between them and sleep apnea, and how they are all important parts of the mix for the future of sleep apnea.

If you want to learn more about the world of sleep apnea, head over to the Dental Sleep Practice website and read the full Perspective article.

Lecture on Jurisprudence for Dental Sleep Medicine

Post is written By Dr. Rogers, D.M.D.

 

Several times a year I have the opportunity to speak on “Jurisprudence for Dental Sleep Medicine Practice” on behalf of our Academy. As a member of the Academy’s Speakers Bureau, I travel the country several times each year sharing information on medical-legal issues for the sleep-disorders dentist. This is a fascinating topic because <i>dental sleep medicine</i> is not completely dentistry or medicine. Rather, it is a unique blend of the two. Snoring and obstructive sleep apnea are medical problems that happen to be treated by a dentist, and so the sleep disorders dentist has one foot in dentistry and the other in medicine. This raises interesting issues such as, “Does the scope of practice of a dental license cover treatment of a medical problem?” Or, given the relative newness of the practice of dental sleep medicine, “What is the standard of care for the practice of dental sleep medicine?” These questions are critical since the dentist may be at risk if these concepts are not thoroughly understood and taken into account. In addition, proper understanding and appropriate clinical protocol also leads to enhanced patient health. The fact of the matter is that all dentists are regulated by their State Board of Dentistry. The good news is that state boards define the practice of dentistry in very broad terms which allows dentists to practice their trade without unduly restrictive regulation. This includes the practice of dental sleep medicine. Over the past 30 years we have seen the gradual formulation “standard of care” and the American Academy of Dental Sleep Medicine and the American Academy of Sleep Medicine have published practice parameters outlining suggested standard of care.

The Pivotal Role Dental Hygienists can play for Sleep Apnea

Post is written By Dr. Rogers, D.M.D.

 

I always enjoy speaking to dental hygienists about dental sleep medicine. And so I had the pleasure to speak to a Pittsburgh dental hygienist’s study club last November. I feel that the dental hygienist can play a pivotal role in screening for snoring and obstructive sleep apnea and start their patients on the journey of treating this serious malady. The dental hygienist has the ability to see their patients on a very regular basis, generally every six months or so. Much more so than in a medical office let’s say. As such, they have the wonderful opportunity to create a friendly relationship over time so during the 30-45 minutes time it takes to clean teeth, the hygienist can query the patient about snoring and possible tiredness during the day, the hallmarks of obstructive sleep apnea. For this to be effective, hygienist needs to have a working knowledge of the causes of sleep apnea as well as the options for treatment. Patients are typically comfortable talking about this because they are generally unaware of the relationship between snoring, upper airway collapse during sleep and sleep apnea. If the hygienist can explain the medical problems that can result from untreated sleep apnea, the patient has the opportunity to improve their health and well-being by being sleep tested and treated (and they have cleaner teeth!).

California Dental Association Journal Chapter, February 2012 Article: Past, Present, and Future Use of Oral Appliance Therapies in Sleep-Related Breathing Disorders

Post is written By Dr. Rogers, D.M.D.

 

As a pioneer in the evolution of Dental Sleep Medicine, I had the privilege of authoring an article in the California Dental Association Journal titled Past, Present and Future Use of Oral Appliance Therapies in Sleep-Related Breathing Disorders. Calling on my past experience over the last 24 years, I outlined the humble beginnings of our now international organization, the American Academy of Dental Sleep Medicine. I was able to chronicle the tenuous beginning of dental sleep medicine when it was not yet backed by scientific research and so was not supported by physicians or insurance carriers and was relatively unknown to the public. Today, our Academy boasts over 3000 members spanning over a dozen countries worldwide. More importantly, the published scientific literature firmly supports the effectiveness of oral appliances to treat snoring and obstructive sleep apnea and physicians are actively seeking dentists to help them treat their patients who are afflicted by this serious malady. In addition, most insurance companies cover the vast proportion of the cost of this therapy when delivered by a properly educated and trained sleep-disorders dentist.   Read the full article here: Past, Present, and Future Use of Oral Appliance Therapies in Sleep-Related Breathing Disorders