The role of the dentist in the management of sleep-disordered breathing (snoring and obstructive sleep apnea) is expanding and most medical sleep teams are including properly trained dentists.
As such, it is incumbent on the dentist with an interest in this field to obtain additional training in sleep medicine as well as oral appliance therapy and to work in tandem with sleep physicians and sleep laboratories. Recent research shows that inadequately managed sleep-disordered breathing can lead to increased risk for high blood pressure, heart attack, stroke, diabetes, depression and other adverse sequelae.
Presently, the dentist who treats any level of sleep-disordered breathing (even simple snoring) without the proper education and without initial medical evaluation jeopardizes the patients well-being and places him or herself at risk medical-legally.
The duties of the dentist include:
- Case detection (not diagnosis)
- Referral for medical diagnosis
- Assess candidacy for oral appliance (OA) therapy
- Select OA design
- Construction, delivery of OA
- Titration of OA
- Treatment follow-up and monitoring
- Management of side effects / complications
- Collaboration with MD
Recognition of the Problem
Dentists can best serve their patients by including a few questions on the medical history form that will suggest the likelihood of sleep-disordered breathing:
- Do you snore?
- Are you tired or sleepy during the day?
- Has anyone ever mentioned that you stop breathing at night?
In addition, a neck circumference of >17 inches in men and >16 inches in women is a risk factor for sleep-disordered breathing, as is obesity. High blood pressure is also frequently associated with snoring and obstructive sleep apnea. In children, enlarged tonsils and adenoids are quite often a cause of sleep-disordered breathing.
The clinical dental exam should strive to focus on the oropharynx where an enlarged tongue, enlarged tonsils, a large uvula, a drooping soft palate, medially displaced tonsillar pillars or retrognathia can predispose to upper airway obstruction during sleep.
When to Refer
If the medical history or the clinical exam is positive for the likelihood for sleep-disordered breathing, the patient should be referred to a qualified medical practitioner for objective diagnosis prior to any treatment. Following a medical diagnosis, oral appliance therapy can be considered in a team-effort with the physician.
Many patients with a previous diagnosis of obstructive sleep apnea have already been placed on continuous positive airway pressure (CPAP) but may have a difficult time accommodating to this therapy. Research indicates that nearly half of those prescribed CPAP cannot tolerate it. In addition, surgical attempts at airway enhancement may not yield adequate results. In these cases, oral appliance therapy is often indicated and effective as alternative treatment.
Articles by Dr. Rogers
- Oral Appliance Therapy for the Management of Sleep Disordered Breathing: An Overview – Sleep and Breathing, Vol. 4, No. 2, 2000
- Review of Oral Appliance Therapy – Sleep Review, Sept. 2000
- Dental Sleep Medicine: Coming of Age – General Dentistry, August 2001
- Word of Mouth – Sleep Review,May/June 2006
- Sleep, Breathing and Orthodontics – Orthodontic Products Online, Aug. 2006
- Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005 – Sleep, VOl. 29, No. 2, 2006. 240-243
- Sleep-Related Obstructive Respiratory Disturbances in Childhood