Brief introduction to medical and dental providers

Provider Adapted from a report by Sara R. Spellman, an 8th grader at Trottier Middle School in Southborough, MA

Sleep apnea is a condition that may be life-threatening. It is a disorder distinguished by short pauses in breathing during sleep and is often characterized by a loud snoring and a choking sensation. There are two different types of sleep apnea: central and obstructive. Central sleep apnea is less common, and happens when the brain does not send the correct signals to the muscles and there is no respiratory effort. Obstructive sleep apnea is more common, and occurs when the airflow through a person’s upper airway is blocked, while respiratory effort continues. People who have sleep apnea can experience daytime sleepiness, insomnia (either sleep onset or sleep maintenance), depression, early morning headaches, decrease in libido, weight gain, urinary frequency and GERD.

The number of unintentional pauses in breathing, in a given night, can be as high as 100 or more an hour. These pauses are frequently accompanied by snoring, but not everyone with sleep apnea snores. It is important that sleep apnea is recognized early because it is linked with increased incidence of high blood pressure, heart attacks, cardiac arrhythmia, stroke and a myriad of other diseases.

There are many reasons for interrupted sleep and sleep apnea cannot be diagnosed by just the symptoms or complaints of the patient. There are a number of tests that are available for screening a person for sleep disorders; the only definitive tests that exists to diagnose OSA is a polysomnograph, or a “sleep study.” Sleep studies (polysomnography) record an number of “channels” of information. A 17 channel study is the ‘gold standard’; this includes: EEG, eye movement (EOG), muscle activity (especially in the anterior tibialis), heart rate, respiratory effort and rate, nasal and oral air flow, and blood oxygen levels Adjunctive testing may include the Multiple Sleep Latency Test (MSLT); a test done the day after a sleep study which measures the tendency of a patient to sleep when in a quiet situation and sleep stage; this test may be used to rule out other sleep disorders such as narcolepsy.

Treatment of sleep apnea is determined by the patient's medical history, physical examination, and the results of the sleep study. Medication has been found ineffective in the treatment of OSA. In some mild cases, changing behaviors is all the person needs to control his/her sleep apnea. The use of alcohol, tobacco, and sleeping pills make the airway more likely to collapse during sleep and extend pauses in breathing. People who are overweight can profit from losing weight; even a ten percent drop in weight can reduce the severity of the disease. Nasal continuous positive airway pressure (nCPAP) is the most common and effective treatment for sleep apnea. Nasal CPAP prevents airway closure while the person uses it; pauses in breathing come back when a person removes the CPAP interface or uses it incorrectly. CPAP can drive off CO2 and decrease the respiratory drive, effectively changing OSA to CSA. Recent research where CO2 is added to CPAP appears to correct this problem.

Dental appliances are another method of treatment; these ‘orthotics’ reposition the lower jaw and tongue to open the collapsed airway similar to CPR). Orthotics are statistically most effective in patients with mild to moderate sleep apnea, or a person who snores but does not have apnea, but are able to treat 40 % of patients with severe OSA comparably to CPAP.

There are numerous surgeries used in the treatment of sleep apnea, although no procedure is without risks or totally successful. Common procedures include the removal of adenoids and tonsils (most effective in children), nasal polyps or other tissue blocking the airway as well as correction of structural deformities. Younger patients seem to benefit more than older people when undergoing surgical procedures. The most common surgical procedure is uvulopalatopharyngoplasty (UPPP), which removes excess tissue at the back of the throat, including the tonsils, uvula, and part of the soft palate. The long-term success of this procedure ranges from 30 to 50 percent. Long-term side effects and benefits are not known and it is difficult to predict which patients will do well with an individual surgical procedure. Other surgical interventions are done with lasers or radioablation (e.g. somnoplasty™), but these are less effective treatments than those done in an operating room. Tracheostomy is presently reserved for patients with severe, life-threatening sleep apnea who are unable to tolerate any other therapy. Extremely obese patients might be recommended for surgical procedures to treat obesity.

No one treatment is effective for every patient. It is important that all physicians treating obstructive sleep apnea be well versed in all of the modalities of treating this disease and make sure the patient receives appropriate information. A team approach to treatment allows the patient more choices of therapy and more chance of finding a successful therapy which matches their life style and improves their quality of life. One patient defined his sleep physician as a “CPAP Nazi” who refused to entertain any other treatment option. All providers need to be open minded about alternative therapies; Our ‘raison d’être’ is to effectively treat the patient with obstructive sleep apnea, not force every patient into a ‘square hole’.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

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The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/