The Dentist’s Expanding Role in OSA

Jamison R. Spencer, DMD, MS, and Shahrzad Firouzabadian, DDS, MS

December 2017 Issue - Expires December 31st, 2020

Inside Dentistry

Abstract

With the substantial increase in the incidence of OSA in the United States during the last couple of decades, it has become all the more important for dentists to participate in the identification and treatment of this potentially deadly condition. Through screening and referral, dentists can partner with physicians to get at-risk patients properly diagnosed, and with an appropriate prescription, they can treat patients with oral appliance therapy. An oral appliance may be used in conjunction with a CPAP device, when it is inconvenient to use a CPAP device, or instead of a CPAP device, especially in situations when adverse effects are preventing the patient from experiencing the benefits of CPAP. This article presents risk factors for OSA, screening protocols, recommendations for referral and testing, treatment options, and more. The mechanisms and features of common oral appliances are discussed as well as considerations for their appropriate selection.

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Obstructive Sleep Apnea (OSA) is a common problem in both adults and children. Accord-ing to a 2014 American Academy of Sleep Med-icine report, data previously published in the American Journal of Epidemiology reveal that the estimated prevalence rates of OSA in the United States have increased substantially during the last 2 decades, most likely due to the obesity epidemic. It is now estimated that 26% of US adults between the ages of 30 years and 70 years have OSA.1

Although other studies have found lower or higher prevalence rates among various populations, it is clear that patients with diagnosed or undiagnosed OSA frequently present to the dental office for routine care.

As healthcare providers who are focused on the oral cavity, dental professionals are literally looking at a portion of the upper airway all day long—a fact that uniquely positions them to evaluate patients for the risk factors of OSA as well as ask screening questions.

Dentists have been involved in the treatment of OSA since the days of Pierre Robin; however, recently, there has been a dramatic increase in dentistry's involvement in OSA evaluation and treatment.2 This is largely due to an increase in evidence supporting the efficacy of oral appliance therapy, the creation of the American Academy of Dental Sleep Medicine and it's connection with the American Academy of Sleep Medicine, the publication of guidelines related to oral appliance therapy, and recognition by Medicare and private medical insurance companies of the role of oral appliance therapy in the treatment of OSA.3,4

The increase in awareness amongst dental professionals regarding OSA is also related to additional evidence suggesting that OSA may be associated with bruxism, periodontal disease, gastroesophageal reflux disease (GERD), temporomandibular joint (TMJ) disorders, and other dental related issues, including those that may arise secondary to these, such as excessive wearing of the teeth, fracture of dental restorations, and failure of dental implants.5-9

This article provides an overview of the treatment of an adult dental patient from initial screening for OSA to placement on long-term recall for oral appliance therapy. Screening and participation in the diagnosis and management of children with OSA is also within the scope of the dental practice, but these treatments mostly approach the disease from the standpoint of early detection and possible prevention. Although the treatment of pediatric sleep-disordered breathing is extremely important, this article focuses on adult patients.

Screening

Screening for OSA in the dental office may be simple and informal or may involve the use of validated questionnaires and specific examination protocols. A common screening tool used in OSA diagnosis is the Epworth Sleepiness Scale. This is an 8-question survey in which the patient rates his or her likelihood of “dozing or falling asleep” on a scale from 0 (not likely) to 3 (highly likely) in eight different situations. Although the Epworth Sleepiness Scale has been correlated with OSA (if the score is higher than 10), dentists should not place too much weight on the results of this questionnaire alone, as sleepiness is only one of the risk factors of OSA.10 Other established risk factors for OSA include the following11,12:

Obesity

Large neck circumference (ie, greater that 17 inches for men and greater than15 inches for women)

Narrow or crowded airway (including large tonsils)

Retrognathia

Male gender

Older age

Family history

Hypertension

Diabetes

GERD (including acid erosion of the teeth)

Use of alcohol and/or sedatives

Smoking

Difficulty breathing through the nose (ie, mouth breathing)

Witnessed apneas

In addition, there are other risk factors that have less published evidence linking them to OSA, including tooth wear (particularly anterior wear), nocturnal bruxism/clenching, periodontal bone loss, mandibular tori, and TMJ disorders. More and more dentists are paying attention to these factors, and the evidence base is building.

The relationship between OSA and many of these risk factors goes both ways. In other words, having OSA also puts you at a higher risk of having hypertension, GERD, and diabetes. It is important to recognize that these are comorbid conditions, and that there isn't necessarily direct causality.

Having more risk factors puts a patient at greater risk of developing OSA, but no singular risk factor can indicate conclusively that a patient has OSA, and conversely, a lack of highly correlated risk factors (eg, a very low score on the Epworth Sleepiness Scale) does not conclusively rule out the presence of OSA.13-15Further diagnostic testing is required.

Using a specific screening form or incorporating questions into the new patient intake form, as well as adding a few items to the intraoral exam, can provide an easy way to screen all patients for possible OSA. When a patient is found to be at risk for OSA, referral for consideration of diagnostic testing is indicated.

Referral

Dentists are not legally permitted to diagnose OSA in the United States. As such, the preferred diagnostic pathway is to refer the patient to a sleep specialist or, if no sleep specialist is available, to his or her primary care provider for evaluation and consideration of objective testing.3

Whenever possible, the dentist is encouraged to refer directly to a physician who is board certified in sleep medicine, because he or she typically will provide a more thorough sleep-related evaluation. If the patient does not fit the stereotypical presentation of the OSA patient, namely, an obese, older male, primary care physicians may be more likely to disregard the risk factors that the dentist has noted. Generally, dentists are more likely to refer healthier and younger patients who do not necessarily fit into the typical OSA mold, which may require a discussion with the sleep physician or primary care doctor to communicate the specific concerns that prompted the referral.

Once the patient has been referred to the physician and evaluated, a decision will be made about whether or not objective testing is indicated. If the physician does not feel that a sleep study is indicated, the dentist may still treat the patient for any dental issues that could contribute to the further development of OSA (eg, bruxism) or request a prescription from the physician to treat the patient's snoring.

Testing

Objective testing is required for an accurate diagnosis of OSA, and in-lab polysomnography is the gold standard test. At-home studies are also widely performed, and in many states, they are preferred or even required by medical insurance companies. However, an at-home study cannot be used to rule out OSA, so if an at-home study concludes “no OSA” but the patient is still considered at-risk, an in-lab study may be indicated.

This is behind one of the arguments against dentists using at-home sleep testing equipment to screen their patients. An at-home sleep test may indicate that a patient has OSA, but in order to be considered valid, the test results must be read and affirmed by a board certified sleep physician, which often requires a face-to-face evaluation with the physician prior to the study. If the at-home sleep test indicates that the patient does not have OSA, but the dentist fears that the results are inconclusive, the patient will still have to see a physician to order an in-lab study.

When a patient is found to have OSA through objective testing (either by in-lab polysomnography or an at-home sleep study), then the physician who ordered the study will typically prescribe therapy.

Treatment

Continuous Positive Airway Pressure (CPAP) is widely considered to be the gold standard therapy in the treatment of OSA. Although it has been shown to be very effective at eliminating OSA among most patients, long-term compliance tends to be poor.

Patients presenting to the dental office who have tried and given up on the use of CPAP will often report experiencing various adverse effects or issues with CPAP that resulted in their discontinuation or limited use of the therapy. Some of the more common complaints associated with CPAP include the following:

Mask leakage or poor fit

Uncomfortably high pressure

Dry mouth, nose, or eyes

Marks on the face from the straps

Claustrophobic associations

Difficulty breathing

Air filling the stomach

Difficulty sleeping

Bed partner disturbance

Along with these reported issues, patients sometimes report that they do not feel any better while using CPAP. Patients who feel better on CPAP tend to put up with the associated side effects, get used to them, or get past them. When patients do not feel better from the therapy (ie, more rested, more energized, less sleepy during the day), they tend to be less tolerant of the side effects.16

Patients who are using CPAP effectively should continue to use it; however, dental treatments may also be appropriate for these patients. For example, a patient may still have issues with bruxism that need to be addressed. If this patient experiences a dry mouth while using their CPAP device, intervention may be indicated to avoid potentially serious dental side effects.

Even patients who use their CPAP device effectively may be candidates for oral appliance therapy. Many patients experience difficulty using their CPAP device when they travel or at other times when it becomes inconvenient. These patients may benefit from the use of an oral appliance in situations where they are unable to, or choose not to, use their CPAP device.17

In other cases, oral appliance therapy may be prescribed to be used in concert with CPAP. So-called “combination therapy” often allows higher CPAP pressures to be lowered, which can result in greater compliance. Although combination therapy can be very effective and particularly helpful for CPAP patients with more severe OSA who require higher pressure, the disadvantage is that the patient now has two therapies to deal with and the possibility of side effects from either the CPAP device, the oral appliance therapy, or both.18

Oral appliance therapy may be prescribed by the physician as a standalone therapy or in conjunction with CPAP for any level of OSA.19 When the OSA is severe (ie, Apnea-Hypopnea Index score > 30), some insurance companies may require a trial of CPAP prior to authorizing the use of an oral appliance, but this is a vestige of outdated guidelines.

If an oral appliance is prescribed as either a first-line treatment, an adjunct to CPAP, or an alternative to CPAP, dental examination and appliance selection is indicated.

Oral Appliance Selection

Dental examination for oral appliance therapy includes a thorough, general examination as well as a focused examination of specific areas of concern related to the provision of the therapy. Some issues to consider when selecting an oral appliance include the following20:

Missing teeth (most appliances require multiple healthy teeth per arch for proper retention)

Periodontal disease and/or mobile teeth (oral appliance therapy may help, but could result in exacerbation)

Clinically short crowns or otherwise non-retentive teeth

Undercuts

Bruxism (particularly lateral wear)

Mandibular tori

History of TMJ disorders

Open contacts

Occlusal issues

In addition, other patient issues that are not directly related to the oral cavity should be considered by the dentist when selecting an oral appliance, including the patient's desire to be able to fully open his or her mouth with the appliance in place or have the appliance help to keep his or her mouth closed, any allergies to metal or acrylic, the bulkiness of the appliance, and any patient concerns about possible side effects.

With more than 100 custom fabricated oral appliances available on the market, as well as a host of non-custom appliances, oral appliance selection can be confusing and overwhelming for many dentists. All oral appliances used in the treatment of OSA and snoring attempt to achieve the same effect: the maintenance of a patent oropharyngeal airway through the stabilization of the mandible and associated soft tissue or by holding the mandible in a forward position. How each appliance accomplishes this is the difference. Oral appliances used in the treatment of OSA and snoring are categorized by the mechanical action that the appliance employs to help prevent the mandible from moving posteriorly and/or actively hold the mandible anteriorly (Table 1).

General custom fabricated appliance designs include anterior pull/push, bilateral push, bilateral pull, interlocking, and mono-block. Although the vast majority of commercially available, FDA-cleared, oral appliances fit into one of these five basic categories, there are a few unique appliances that do not. There are also various non-custom, or “temporary” appliances available, which usually fall into one of the above mechanism categories as well.21

References

1. Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006-1014.

2. Gangopadhyay N, Mendonca DA, Woo AS. Pierre Robin Sequence. Semin Plast Surg. 2012; 26(2):76-82.

3. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an american academy of sleep medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479-504.

4. Local Coverage Determination (LCD): Oral Appliances for Obstructive Sleep Apnea (L33611) Page.

https://med.noridianmedicare.com/documents/
2230703/7218263/Oral+Appliances+for+Obstructive+Sleep+Apnea+LCD+and+PA/dc994aa8-c706-438b-9e31-db18a6be1358. Updated January 1, 2017. Accessed October 9, 2017.

5. Anitua E, Saracho J, Almeida GZ, et al. Frequency of prosthetic complications related to implant-borne prosthesis in a sleep disorder unit.  J Oral Implantol. 2017;
43(1):19-23.

6. Duran-Cantolla J, Alkhraisat MK, Martinez-Null C, Aguirre JJ, Guinea ER, Anitua E. Frequency of obstructive sleep apnea syndrome in dental patients with tooth wear. J Clin Sleep Med. 2015;11
(4):445-450.

7. Hawrylkiewicz I, Plywaczewski R, Dziedzic D, et al. [Gastroesophageal reflux disease (GERD) in patients with obstructive sleep apnea syndrome (OSAS)]. Pneumonol Alergol Pol. 2006;74 (4):361-364.

8. Heinrich R. Sleep apnea for dentists: an overview of signs, symptoms, consequences, and treatment. Dental Academy of Continuing Education. Oct. 2013. https://www.dentalacademyofce.com/courses/2526/pdf/1310cei_heinrich_web.pdf.

9. Okeson JP, Phillips BA, Berry DT, et al. Nocturnal bruxing events in subjects with sleep-disordered breathing and control subjects. J Craniomandib Disord. 1991;5(4):258-264.

10. Johns W. A new method for measuring daytime sleepiness: the epworth sleepiness scale. Sleep. 14
(6):540-545.

11. Aurora RN, Punjabi NM. Obstructive sleep apnoea and type 2 diabetes mellitus: a bidirectional association. Lancet Respir Med. 2013;1(4):329-338.

12. Pamidi S, Tasali E. Obstructive sleep apnea and type 2 diabetes: is there a link? Front Neurol. 2012;3:126 eCollection.

13. Lurie A. Cardiovascular disorders associated with obstructive sleep apnea. Adv Cardiol. 2011;46:197-266.

14. Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010;182(2):269-277.

15. Stone KL, Blackwell TL, Ancoli-Israel S, et al. Sleep disordered breathing and risk of stroke in older community-dwelling men. Sleep. 2016;39(3):531-540.

16. Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. June 2013;110(6):896-914.

17. Sutherland K, Phillips, CL, Cistulli, PA. Efficacy versus effectiveness in the treatment of obstructive sleep apnea: CPAP and oral appliances. Journal of Dental Sleep Medicine. 2017;4(3):175-181.

18. Vanderveken OM. Combination therapy for obstructive sleep apnea in order to achieve complete disease alleviation: from taboo to new standard of care. Journal of Dental Sleep Medicine. 2015;2(1):7-8.

19. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J of Clin Sleep Med. 2015;11(7):773-827.

20. AADSM Treatment Protocol: Oral Appliance Therapy for Sleep Disordered Breathing: An Update for 2013 Page. http://www.aadsm.org/treatmentprotocol.aspx. Updated June 2013. Accessed October 9, 2017.

21. Essick GK, Blank AR, Spencer JR, et al., Part IV: oral appliance therapy for sleep-disordered breathing. Inside Dental Technology. 2016;7(12):34-39.

Table 1

Table 1

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SOURCE: Inside Dentistry | December 2017

Learning Objectives:

  • Identify some of the various risk factors of OSA.
  • Describe the objective in-lab and at-home tests used in the diagnosis of OSA.
  • Discuss the use of CPAP therapy in the treatment of OSA, including potential issues and adverse effects that may result in reduced efficacy and/ or poor patient compliance.
  • Discuss the use of oral appliance therapy in the treatment of OSA, including dental concerns, patient- specific needs, and other considerations for appropriate device selection.