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Dental Sleep Medicine

What is Dental Sleep Medicine? Sleep Medicine is the study and treatment of patients with sleep disorders. These disorders range from simply needing to change a person�s sleeping habits (Sleep Hygiene), to underlying anatomical problems (Obstructive), to central nervous system problems (Neurologic based, CNS). Dental sleep medicine is the study and treatment of patients that have Sleep Hygiene problems or Obstructive problems. Most obstructive problems come from a combination of, but not limited to, large neck size, large tonsils/adenoids, large tongue base, overweight, nasal obstructions, narrow palate, and large uvula. Since most obstructive problems involve the oral cavity, dentists become a key part of the sleep team.

Who can diagnose a Sleep Disorder? Only a physician can diagnose a sleep disorder! The most common test to diagnose a sleep disorders is a polysomnogram. Once a diagnosis is made, the physician can discuss treatment options.

Common Sleep Disorders:

Sleep Hypopnea � A decrease in breathing but not the cessation of breathing.

Sleep Apnea - A temporary and often repeated cessation of breathing during sleep.

Snoring � A noise produced when sleeping due to an increase in air resistance due to the narrowing of the airway and a resulting vibration of the uvula.

Hypersombulance � Excessive daytime sleepiness.

Narcolepsy - A neurological disorder marked by a sudden recurrent uncontrollable compulsion to sleep.

Obstructive Sleep Apnea

This is the area of sleep medicine that can involve the dental team. Obstructive Sleep Apnea (OSA) is just as the name indicates. Apnea, the cessation of breathing, is caused by the complete blockage of the airway while sleeping. The diagram below illustrates the basic flow for a person with OSA.

Sleep � Nervous system changes to a parasympathetic state there is a decrease in muscle tone � the hypoglossal muscle relaxes and the tongue drops back closing off the airway � there is a decrease in Oxygen to the brain � this causes an �Arousal� which sounds like a gasping for air � there is then a sympathetic reflex sent by the central nervous system � an increase muscle tone occurs in the hypoglossal muscle � the airway opens � and the bodies oxygen level increases.

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Imagine doing this 10 -20 times an hour while trying to sleep! Do you think you would get a good night sleep under these circumstances? Is that snoring just snoring you�re hearing or is it something far worse?

So what does this mean to me? Why should I be concerned?

It has been said that no one dies from an apnea episode, but people can die from the problems it creates. Remember, Oxygen is everything! Without it we die!

The associated problems with sleep apnea are what cause morbidity and mortality problems for those patients. Some of them are listed below.

1. Hypertension (high blood pressure)

2. Atrial fibrillation (can result in blood clots forming in the heart chamber)

3. Stroke

4. Diabetes

5. Difficult weight loss (which compounds the obstructive problems)

6. Hypersombulance (sleepiness at work or driving)

7. Headaches/ migraines

8. Marital problems (ever try and sleeping with a snorer/person with sleep apnea? Covering their mouth with the pillow is not the answer!)

The bottom line is if you think you or someone you know has a sleep disorder, get to a qualified sleep physician and get tested!! Knowing is better than not knowing. At least then you can weigh out your options.

Take the Test! Try the following screening questions to see if you have a tendency for a sleep disorder. Then take the Epworth Sleepiness Scale and see if the six warning signs and the sleepiness scale point towards you having a possible sleep disorder.

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?

Epworth Sleepiness Scale

How likely are you to fall asleep in the following situations?

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Activity Score

Sitting and Reading ______

Watching Television ______

Sitting, inactive, in a public place (theater, meeting) ______

As a passenger in a car for an hour with no break ______

Lying down to rest in the afternoon, if circumstance permits ______

Sitting and talking to someone ______

Sitting quietly after lunch without alcohol ______

In a car while stopped for a few minutes in traffic ______

Total Score ______

Epworth Interpretation

It is unlikely that you are abnormally sleepy
you have an average amount of daytime sleepiness
You may be excessively sleepy depending on the situation. You may want to consider seeking medical attention.
You are excessively sleepy and should consider seeking medical attention.

Keep in mind this is a simple screening and only a qualified sleep physician can determine if you have a sleep disorder.

The gold standard today for treating mild to moderate obstructive sleep apnea is CPAP. However, the American Association for Sleep Medicine now recognizes Oral Appliance Therapy (OAT) as an alternative to CPAP in mild to moderate sleep apnea cases.

Your sleep Physician will most likely recommend CPAP to start. If you are unable to tolerate or if you refuse to use CPAP then you should discuss with the Physician, Oral Appliance Therapy. The compliance rate for CPAP unfortunately is very low due to the cumbersome machine and hoses used to deliver the continuous positive air pressure. Oral Appliance therapy is easy to use but also can have associated problems. These would include muscle soreness and potential changes in your bite. No treatment at this time is perfect. You just need to find the right option for you and always keep in mind, Oxygen is everything!

Below are a few pictures of Oral Appliances for Obstructive Sleep Apnea. There are currently 85 types of appliances and they all work. Some however, are more comfortable than others and may have fewer side effects. When OAT is chosen, then retesting is recommended to be sure it is helping decrease the apnea episodes. CPAP therapy should also be retested to be sure it is helping.