Download CONTINUING EDUCATION To be published in Inside Dentistry Fall 2008

CONTINUING EDUCATION
To be published in Inside Dentistry Fall 2008
Dental Sleep Medicine
Barry Glassman, DMD
Barry Glassman, DMD
Private Practice Limited to Chronic Pain Management, Temporomandibular Joint Dysfunction,
and Dental Sleep Medicine
Allentown, Pennsylvania
ABSTRACT
It has been estimated that 16 million people have undiagnosed obstructive sleep disorders,
including sleep apnea. These disorders are associated with some serious comorbities
including stroke, heart attack and diabetes. Furthermore, many who have been properly
diagnosed are unable to use the most commonly prescribed treatment, continuous positive
airway pressure. The purpose of the paper is to describe the key role that dentistry can
play in providing an effective alternative treatment modality. The dentist providing such
services must understand the basics of sleep medicine, which are reviewed. The dentist
must understand his key role in not only identifying his patients who may be affected by
sleep apnea, but also by referring those patients for comprehensive diagnosis and triage for
appropriate therapy. Appliance therapy and treatment of untoward side effects are
reviewed.
LEARNING OBJECTIVES
After reading this article, the reader should be able to:
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describe the stages of sleep.
discuss the role of the dentist in diagnosis and treatment of sleep-disordered breathing.
outline the method of action of oral appliance therapy.
explain the possible unwanted effects of oral appliance therapy.
describe the screening process for identifying the potential presence of an obstructive
disorder.
Sleep medicine is a young subspecialty. The medical community is becoming more aware of the
significant role that sleep disturbances play in patients’ general health. Physicians who treat sleep
disorders clearly understand the relationship between sleep and chronic pain, and they appreciate
the key role sleep plays in healing from both micro-trauma and macro-trauma. Many physicians
have acknowledged a concern for the social problems associated with snoring. Most importantly,
a greater understanding of the serious co-morbidities of hypertension, myocardial infarctions,
stroke, weight gain, diabetes, acid reflux, and excessive daytime sleepiness leading to work and
home injuries as well as motor vehicle accidents has made the treatment of sleep disorders a high
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priority. Medical professionals now understand that chronic sleep deprivation is related to a
shortened life expectancy, and that quality sleep is potentially associated with improved overall
mental and physical health.
Although there is still much about sleep physiology that remains a mystery, the science of sleep
medicine has improved dramatically in recent years. While, like any new science, there is much
to be learned, the recent awareness and improvements in therapy already have led to an improved
quality of life for many patients. Yet, 90% of people with sleep-disordered breathing remain
undiagnosed.1 The American Society of Anesthesiologists estimates that 16 million people have
undiagnosed sleep disorders.2
The role that dentists can play in this critical field is extremely important.3,4 Many dentists tend
to see their patients on a more regular basis than general physicians; consequently, it is very
important that dentists learn to ask the proper questions so proper referrals can be made. In the
best interest of patients’ needs, it is equally important that dentists avoid the pitfalls that can lead
to improper therapy or a competitive environment with the very sleep physicians with whom
they need to function in harmony. Providing treatment for patients who snore without
formulating a complete and accurate diagnosis is problematic. This approach, based solely on a
patient’s report of snoring, can be compared with treating gingival hyperplasia without a proper
diagnosis, including periodontal probing and radiographs. If the snoring is resolved, the patient
often will not seek further therapy. Consequently, the obstructive disorder may continue and the
patient remains at risk for hypertension, stroke, diabetes, and the other associated comorbidities.5 Just as treating gingivitis without proper diagnosis would be considered below the
standard of care, treating obstructive disorders carries the same diagnostic requirements. The
consequences of sleep disturbances are potentially more severe than tooth loss from underlying
periodontitis.6 In addition, any treatment of snoring without including the medical profession
widens the gap between the professions, the same gap that needs to be narrowed to treat the vast
majority of patients with obstructive sleep apnea appropriately.
NORMAL SLEEP STAGES
(Author’s note: for a comprehensive presentation on sleep physiology see :
Kryger, M.H., T. Roth, and W.C.
Dement, Principles and practice of sleep medicine. 4th ed. 2005, Philadelphia, PA:
Elsevier/Saunders. xxxiii, 1517 p.)
Normal sleep is divided into two types: non-REM (NREM) and REM.7-9 REM sleep is, of
course, rapid eye movement. NREM sleep is divided into four distinct stages. Stages one through
four are determined by alterations in brain wave activity as recorded in an electroencephalogram
(EEG). Physiological changes occur with each sleep stage. During sleep, the body is considered
to be in an inactive state while the brain remains active. A normal sleep pattern has four to five
cycles throughout the night. NREM and REM sleep states alternate in cycles that usually last
between 90 and 110 minutes. Normal NREM sleep occupies 75% of the night, and is
characterized by a decrease in body temperature, blood pressure, breathing rate, and most
physiologic functions. REM sleep is characterized by a highly active brain in an essentially
paralyzed body.10,11
2
As a result of this pattern, normal sleep presents with specific relative time spent in each stage.
Arousals (events that alter normal stage progression) cause alteration of this normal architecture
and often are responsible for sleep disturbances and hyper-somnolence, which is defined as
excessive daytime sleepiness (Figure 1) Arousals can be caused by partial obstructions leading to
snoring or difficult breathing, complete obstructions defined as apneas, nonobstructive
conditions such as pain, central apneas (a stoppage of breathing from lack of respiratory effort as
opposed to an obstruction), involuntary body movements, or even psychological situations. Of
extreme importance to dentists, arousals can be associated with the parasomnia of bruxism.12,13, 14
Consequently, parafunctional control has the potential to decrease the arousal index (the number
of arousals per hour of sleep) and improve the quality of sleep.
In NREM stage one, sleep usually occupies approximately 5% of the sleep cycle, and is
represented by a relatively active brain-wave pattern. Stage two is represented by active brain
waves that include specific EEG patterns called K-complexes and sleep spindles (Figure 2). This
stage usually occupies 45% of the sleep cycle. Stages three and four combined are referred to as
slow-wave sleep. Earlier in sleep medicine these stages often were referred to as Delta sleep.
These stages represent progressively deeper sleep, are identified by slow high-amplitude brain
waves, and usually occupy approximately 25% of the night’s pattern These percentages do alter
as patients age, with slow-wave sleep decreasing significantly in the sixth and seventh decades
Various medications as well as the existence of chronic pain also have effects on sleep
architecture.15
REM sleep is characterized by rapid eye movement, irregular breathing, relative skeletal muscle
paralysis, and an irregular heart rate. It is when most of the colorful and vivid dreaming occurs,
and it occupies 20% to 25% of the normal sleep cycle REM latency refers to the amount of time
it takes from sleep onset to the first period of REM. Normal REM latency is about 90 minutes,
and can be compromised with significant sleep debt or specific sleep disorders, such as
narcolepsy.7-9
The gold standard for diagnosis of sleep disorders is the polysomnogram (PSG).16 (Figure 3).
These overnight studies take place in sleep laboratories. Patients are monitored through the night.
The PSG monitors brain waves (EEGs to determine sleep stages), eye movements (electrooculogram [EOG]), muscle tone (electromyography [EMG]), nasal air flow, blood oxygen levels,
respirations, cardiac function, and respiratory effort. From these studies, physicians can
determine if there is an alteration in patients’ normal sleep architecture. Patients are monitored
throughout the night and often videotaped. The sleep studies then are scored, and among the
plethora of information received and calculated is the respiratory disturbance index (RDI).17 The
RDI represents the number of hypopneas (which has several definitions, the most common of
which is a 3% drop in blood oxygen levels) plus apneas (universally described as total
obstruction of air flow for 10 seconds or longer) per hour plus respiratory effort related arousals
(RERAs) (drops in oxygen levels associated with arousals that do not meet the criteria of an
hypopnea)7
EMGs on leg muscles are used to evaluate the existence of periodic leg movements. Recently,
3
the placement of the surface EMG electrodes on the elevator musculature has allowed physicians
to look more closely at parafunction 18
CLASSIFICATION OF SLEEP DISORDERS
Sleep disorders are classified as dysomnias and parasomnias. Dysomnias are disorders of
initiating and maintaining sleep, as well as disorders of excessive sleepiness. Examples of
dysomnias are narcolepsy, insomnias, circadian rhythm disorders (eg, jet lag), and obstructive
sleep disorders including sleep apnea.7 Parasomnias are undesirable physical phenomena that
occur during sleep, such as sleep walking, nocturnal leg cramps, periodic leg movements,
nightmares, and bruxism.7-9
Obstructive breathing disorders fall on a continuum beginning with snoring, continuing with
upper-airway resistance syndrome and hypopnea with associated hypoxemia, and ending with
sleep apnea (Figure 4). An apnea is defined as the stoppage of breathing for 10 seconds or more7.
If the stoppage of breathing is caused by an obstruction in the airway, it is called an obstructive
sleep apnea. Obstructive apneas are a result of the blockage of the airway, either at the junction
of the oropharynx (soft palate and base of the tongue) or anywhere else in the pharyngeal
anatomy (Figure 5). When the blockage occurs in the pharynx because of muscular collapse at
that site, the pharynx is said to be compliant. Most often obstructive apnea is a result of more
than one site of obstruction.19 Central apnea refers to stoppage of breathing for 10 seconds or
longer, not as a result of an obstruction but from the lack of respiratory effort.7 Often when there
are central apneas, there are also obstructive apneas, and this condition is referred to as mixed
apnea. For a diagnosis of central apnea to be made, 80% of the apnea events must occur
centrally.7
Dentists can play a major role in the treatment of obstructive disorders. An understanding of
these disorders, the method of action of oral appliances (Figure 6 through Figure 9), and the
potential dental and non-dental side effects of these oral appliances will be the focus of the next
section.
DENTAL SLEEP MEDICINE
Snoring is at the beginning of the continuum of sleep disorders. Snoring can be more than a
social issue; not all snoring is benign. Therefore, all snoring patients need to be diagnosed as to
whether they have a more complex obstructive disorder. As stated previously, treating snoring
without a complete diagnosis is not advisable. An incomplete diagnosis could result in a missed
opportunity to identify a more significant sleep-disordered breathing condition and possibly
protect the patient from the life-threatening co-morbidities associated with obstructive sleepdisordered breathing.
It has been estimated that 90% of all patients with obstructive sleep disorders remain
undiagnosed.20 The reasons are numerous. The best diagnosis can be made after a
polysomnogram, a laboratory-controlled all-night sleep study that is admittedly cumbersome, not
entirely reliable, and often not available.21 Clearly, alternative available testing procedures need
to be considered. 22
Family physicians often do not ask questions related to sleep, and family physicians do not see
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patients at the rate patients are seen by dentists. When asked why questions about sleep, such a
critical aspect of health, are not included during examinations or interviews, family physicians
refer to the limited amount of time they have for an examination as well as their frustration with
the diagnostic procedures and treatment options. 23 It is clear that the dentist’s role can be
significant in helping to identify patients with sleep-disordered breathing, as well as to give the
many patients who have difficulties using continuous positive airway pressure a potentially
successful alternative. The dentist, therefore, can play a role in both diagnosis and treatment.
THE DENTIST’S ROLE IN DIAGNOSIS
No profession has been as successful as dentistry in the field of prevention. A patient is more
likely to see his dentist on a regular basis than any other healthcare professional. 24 It was long
ago determined that dentists could play a major role in helping to uncover potential health risks
in their patients. Medical updates on 6-month or yearly recall visits often include questions about
basic health issues and blood pressure recordings. There is a movement in the dental and medical
fields to educate dentists to ask basic questions about their patients’ quality of sleep. 25
By simply asking if patients snore and if they wake up and feel refreshed, dentists can screen
patients with additional questions (Table). Neck circumference alone has been shown to be an
excellent predictor of apnea.26,27 Additional questions about excessive daytime sleepiness, the
presence of witnessed apneas, or difficulty in falling asleep or staying asleep can be helpful.
Further questioning related to many of the co-morbidities associated with sleep-disordered
breathing also may lead dentists to referral to the proper sleep specialist and/or other medical
specialist. These questions should not only be related to hypertension and excessive thirst, but
also about oral acidity and esophageal burning.28
During the dental examination, dentists should look for excessive wear facets, which are likely to
be a combination of parafunction and oral acidity. Obvious enamel defects from acid, including
dentinal pooling (Figure 10), should be noted. Often the first signs of gastroesophageal reflux
disease (GERD) are odontogenic, and there is a relationship between GERD and sleep apnea,
with a proposed pathophysiology related to alterations in thoracic and abdominal pressure
gradients.29, 30
Positive responses should lead to referral to the sleep specialist. While the polysomnogram is
indeed the gold standard in sleep medicine’s diagnostic regimen, various home-testing units are
available (Figure 11). Many of these testing devices provide valuable information, yet they have
some deficiencies as well.31, 32
Most of them, at this point in time, do not evaluate EEG patterns and consequently do not detect
alterations in sleep architecture. The lack of supervision with these home-testing units remains a
concern; thus, at this time, these testing procedures generally are considered excellent screening
devices but are not considered diagnostic by themselves and are generally not reimbursable by
third-party payers in the United States. It is this author’s opinion, as well as the position of the
American Academy of Dental Sleep Medicine, that while it may be, in some instances, in the
patient’s best interest to have this ambulatory screening study completed, it is the responsibility
of the dentist to then refer the patient to a sleep specialist for diagnostic purposes.33 It is essential
to understand that there are non-obstructive sleep disorders that can be contributing to a patient’s
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signs and symptoms. Making a referral with information gained from the history and/or
screening testing is an excellent service dentists can provide their patients.
THE DENTIST’S ROLE IN TREATMENT
It is generally accepted that the gold standard of treatment for patients with sleep apnea is the use
of continuous positive airway pressure (CPAP).34 This effective therapy uses positive airway
pressure to create a pneumatic air splint, reducing pharyngeal compliance. The amount of
pressure required for each patient is determined in a titration procedure in a sleep laboratory.
While it is a very effective therapy, patient compliance remains the most difficult obstacle to
successful treatment. Despite recent improvements, which include a change from constant
pressure to alternating pressures for inhalation and exhalation (called BiPAP), the addition of
warm air humidifiers, and smaller more portable and quieter units, compliance after 6 months on
many studies is well below 50%. 35 Patients report problems with the fitting of the mast, air
leakage, skin reactions to the air pressure, stomach bloating, claustrophobia, noisy machines,
inability to initiate and maintain sleep, and total inconvenience.36-38
Options to CPAP use include either a surgical procedure or the use of an oral appliance. Surgery
options were at one time very often performed. While the reported rate of success for the various
surgical procedures vary, there is a significant level of pain 41 associated with the most common
procedure (uvulopalatalphyrgolplasty) and the most recent rates of success measured at 6 months
are reported to be below 50%, with the percentage dropping over time 39 (Figure 12)
A laser-assisted procedure was very commonly used, but essentially has been abandoned because
of its low level of success.40 Other procedures include bimaxillary orthognathic surgery and, in
severe cases, tracheostomies. Both of these procedures tend to be very successful, but are, of
course, not considered conservative therapies 41 Therefore, many careful considerations must be
made before either procedure is recommended.
In 1995, a landmark study by Schmidt-Norwarwa and colleagues reported that the use of oral
appliance therapy was effective for mild to moderate sleep apnea.42 A more recent study
showed successful outcomes using this therapy for severe apnea in some cases.43 In addition,
many sleep specialists consider the use of oral appliance therapy the treatment of choice for
primary snoring and upper airway resistance syndrome.44,45 Many patients who use CPAP
therapy successfully use oral appliance therapy when traveling or in combination with their
CPAP device, which allows the low pressure to be more effective. When given the alternatives,
many patients who do not comply with their CPAP therapy choose an oral appliance as their
treatment of choice. 46 The long-term compliance of oral appliance therapy is much higher than
that of CPAP therapy. 47-50 Clearly, oral appliance therapy plays a significant role in the
treatment of patients with obstructive sleep disorders. In 2006, the American Academy of Sleep
Medicine released their policy statement on oral appliances: Oral appliances are indicated in
patients with mild to moderate [obstructive sleep apnea] who prefer their use to continuous
positive airway pressure (CPAP) treatment or who are inappropriate candidates for or who are
refractory to CPAP treatment.33 This statement does not suggest that oral appliance therapy
should be the first line of therapy in all cases, nor does it suggest that it is inappropriate for
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severe cases.
The method of action of the oral appliance is well understood. By maintaining the mandible in a
forward posture, the base of the tongue is pulled forward through the action of the genioglossus
muscle (Figure 13). At the same time, action on the tensor veli palatine muscle is initiated
through the attachments of the base of the tongue through the mandible and the
pterygomandibular raphe. In addition, the alteration in the compliance of the pharynx with oral
appliance therapy indicates a change in the tone of the pharyngeal musculature during sleep,
including REM sleep, during which the musculature would normally be most compliant.
Magnetic resonance imaging of the pharynx with the oral appliance in place has demonstrated an
increase in the airway in the lateral dimension.51 Thus, the appliance is doing more than simply
pulling the tongue forward and creating a decreased possibility of obstruction at the junction of
the base of the tongue and the soft palate. Most often, obstructions occur at more than one site,
and oral appliances remain potentially effective in these cases.
Specific training is required to treat patients with sleep-disordered breathing. Dentists should
understand the nature of patients’ dysfunctions and work in a coordinated effort with sleep
specialists. Dentists should discuss at length with their patients the possible side effects of oral
appliance therapy, which include excessive salivation, temporomandibular joint pain, muscular
pain and soreness, morning maladaptive mandibular posture, and occlusal changes, 46 (Figure 14)
Treatment of these side effects involves joint and muscular therapy, the use of a leaf gauge on
wakening as part of an occlusal maintenance program, and palliative therapeutic measures.
Patient monitoring must be initiated with adaptation to the appliance, followed by guiding
titration33 (Figure 15).
The patient and dentist must work together and make well-advised risk vs benefit decisions
during the treatment process. Too often there is a tendency for the dentist to be overly concerned
about dental changes that may not affect function or esthetics, causing therapy to be abandoned
when it is essential to the patient’s health. The treating dentist must be aware of the anatomy and
physiology of the temporomandibular joint so that strains created in the joint can be recognized
and treated as opposed to aborting oral appliance therapy, possibly prematurely.
CONCLUSION
Obstructive sleep disorders have the potential to negatively alter patients’ quality of life. Not
only can the associated snoring be disruptive to the sleeping pattern of bed partners, but
excessive daytime sleepiness, altered sleep architecture, and the co-morbidities of hypertension,
cardiac disease, stroke, and GERD can debilitate patients further, decrease their quality of life,
and significantly decrease their life expectancy. The vast majority of patients with sleepdisordered breathing are not diagnosed. Dentists have the potential to play a major role in both
initiating diagnostic procedures and treating these patients.
Dentists should not be cavalier and treat snoring, the first stage of this disease continuum,
without a proper diagnosis. They must learn to work hand-in-hand with the medical community.
Dentists must learn how to communicate on a regular basis and learn how to keep referred-to
physicians in the treatment loop. The treatment of sleep-disordered breathing is an art and a
science, and to be successful, the dentist must be adept at both.
7
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Table: Screening Questions
 Do you snore?
 Do you have high blood pressure?
 Has anyone reported that you choke or gasp for air while sleeping?
 What is your neck size? (inches)
 Do you wake refreshed?
 Are you excessively tired during the day?
Figure Captions
Figure 1 The Epworth Sleepiness Test is used to evaluate excessive daytime sleepiness.
Figure 2 K complexes and sleep spindles are EEG patterns specific to Stage 2 sleep.
Figure 3 A polysomnogram records 16 or more channels of a patient’s sleep physiology while in
a sleep laboratory.
Figure 4 Sleep-disordered breathing is a continuum. Diagnosis is required before treatment is
considered.
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Figure 5 Obstructive sleep disorders commonly have obstructions at more than one level.
Figure 6 The SomnoDENT is a titratable, custom, durable appliance produced by
SomnoMED. The anterior/posterior titration can be readily accomplished by the patient.
Figure 7 The author’s preference is to use appliances with anterior midpoint stops for
parafunctional control. This SomnoDENT demonstrates the anterior contact option.
Figure 8 The TAP® III (Comfort Acrylics, Inc,Camas, WA) is a Thornton Anterior Positioner.
This version has thermacryl on the interior that allows for easy adaptation with dental changes.
Figure 9 The TAP III is titratable by the patient. Titration of this appliance will control the
protrusion of the mandible. Both the TAP and the SomnoDENT provide patient friendly
titration, which is extremely helpful as adjustments are made to assure comfort and yet
provide adequate muscular tension.
Figure 10 Dentinal pooling and incisal scooping may be among the first signs of GERD, which
can be a precursor to Barrett’s Syndrome.
Figure 11 Ambulatory tests can be used in medicine and dentistry. Dentists use them for
screening before referring to a medical professional or making decisions about titration of an oral
appliance.
Figure 12 The uvulopalatalphyrgolplasty procedure can be effective for sleep-disordered
breathing but the lack of predictability of the success of the surgery, combined with a difficult
postsurgical course, has decreased the frequency the surgery is recommended.
Figure 13 The SomnoDENT is made by SomnoMED. The quality control of this appliance is
excellent, and it is durable and comfortable.
Figure 14 One of the complications of oral appliance therapy can be the development of
posterior open bite. It is not common, but when it occurs usually function is not altered. It is
essential that an informed risk/benefit decision is made.
Figure 15 A key is used by the patient who is given a specific schedule to titrate the appliance in
the anterior direction.
CE Quiz
1.
a.
b.
c.
d.
What percentage of people with obstructive disorders remain undiagnosed?
60%
70%
80%
90%
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2.
a.
b.
c.
d.
The co-morbidities of sleep disorders include all except the following:
stroke.
diabetes.
narcolepsy.
hypertension.
3.
Dentists should not treat snoring without a complete diagnosis because:
a.
snoring is not a significant enough problem.
b.
treating the snoring may leave the patient at risk for associated co-morbitities and widens
the gap between the medical and dental professions.
c.
dentists should not treat snoring.
d.
snoring is the most difficult obstructive disorder to treat.
4.
a.
b.
c.
d.
A normal sleep pattern has how many cycles throughout the night?
two to three
four to five
eight to nine
ten to twelve
5.
a.
b.
c.
d.
The gold standard for diagnosis of sleep disorders is the:
polysomnogram.
electrocardiogram.
electro-oculogram.
electromyogram.
6.
a.
b.
c.
d.
An apnea is defined as the stoppage of breathing for at least:
5 seconds.
6 seconds.
10 seconds.
15 seconds.
7.
For a diagnosis of central apnea to be made, how many of the apnea events must occur
centrally?
a.
25%
b.
40%
c.
65%
d.
80%
8.
a.
b.
c.
d.
While home studies (ambulatory studies) can be excellent, most do not evaluate:
blood oxygen levels.
snoring.
body position.
EEG patterns.
9.
While CPAP is generally accepted as the gold standard for patients with sleep apnea, the
most difficult obstacle to successful treatment is:
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a.
b.
c.
d.
difficulty determining the proper pressure to use.
cost.
availability.
compliance.
10.
The method of action of an oral appliance does not include which of the following?
a.
By maintaining the mandible in a forward posture, the base of the tongue is pulled
forward.
b.
Action on the tensor veli palatine muscle is initiated.
c.
Keeping the mouth open throughout the night encourages breathing.
d.
There is a change in the tone of the pharyngeal musculature during sleep.
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