Sleep apnea: Listening closer for the telltale signs of dental patients not sleeping well

By Jeff Rodgers, DMD

It’s a typical day on the job: you see several patients, observe and clean their teeth and get them ready for a visit from the dentist. As you’re cleaning one patient’s mouth, something seems a little off. You notice that they have a large neck, and it’s difficult to see their soft palate as they say “Ahhhh.” When you ask the patient about their week, they complain that they’ve been feeling tired and haven’t been sleeping well at night. You’ve experienced patients with a similar story and appearance before. What’s the connection?

As a dental hygienist, you are a critical component of your patient’s systemic and oral health. Research shows that 24.1% of patients are more likely to visit their dentist than their physician for an annual exam, which places a responsibility on you to be knowledgeable about the oral signs that may be indicative of a larger health condition.(1)

Obstructive sleep apnea (OSA) is a common disorder that research indicates affects 1 in 15 adults.(2) It is also the most common undiagnosed sleep disorder and chronic disease in Western society,(3) with up to 80 percent of people that suffer from moderate to severe OSA unaware of their condition.(4)

The condition originates in the throat, which makes you the front line in detection of the physical signs that a patient may suffer from if they have OSA. Once you know the common anatomical traits of patients with the disorder, you can administer simple screening tools during an annual checkup to determine a patient’s risk factor. From there, you can refer a patient to a physician for further evaluation and treatment. The purpose of this article is to inform you about OSA to help you educate patients about the disorder, as well as help you learn more about your importance in detecting and screening for sleep apnea.

What is obstructive sleep apnea?

Obstructive sleep apnea (OSA) is characterized by pauses in breathing or shallow breathing during sleep. Sufferers of the disorder experience an irregular relaxation of the muscles while resting. When these muscles relax, it diminishes the support of the soft palate, uvula, tonsils and tongue.(4) Without support, any one of these oral tissues can partially obstruct the airway, causing the patient to stop breathing for anywhere from 10 to 20 seconds.(5)

To initiate breathing once again, the body abruptly rouses itself from sleep. Severe OSA sufferers may experience over 30 interruptions per hour.(6) These cessations in breathing disrupt the sleep cycle and the benefits of quality, restful sleep, but often the patient might not even remember being roused during the night.

Obese patients, patients with chronic nasal congestion, and smokers are more likely to have obstructive sleep apnea.(4) Obesity is considered the greatest risk factor, as even a person with mild to moderate obesity increases their risk for developing OSA.(7) Men have a higher propensity (almost double the likelihood of women) to develop the condition.(4) Women do not always display the more classic symptoms of obstructive sleep apnea, such as daytime fatigue and snoring. Instead, women may suffer from conditions like depression or insomnia.(8)

The most common symptoms of OSA are loud, chronic snoring, daytime fatigue, witnessed cessations of breathing during sleep and waking from sleep with a gasp or choking sound. Other symptoms include morning headaches, a sore throat or dry mouth in the morning and high blood pressure. OSA sufferers often experience an inability to concentrate or focus on everyday tasks because they experience repeated microarousals, which eliminate the opportunity to have complete restorative sleep cycles.

The disorder is linked to a number of comorbidities, including cardiovascular disease, type 2 diabetes, stroke and even Alzheimer’s. Those that suffer from OSA are two times more likely to get into a car wreck, as sleep apnea causes a decrease in cognitive functioning.(9)

What to look for

Patients with OSA display many symptoms that can be observed simply by looking into the mouth. Common anatomical characteristics include:

• Small or recessed chin
• Large neck circumference
• Scalloped tongue
• Overbite or Shimbashi < 18 mms
• Enlarged tonsils
• Eroded enamel
• Decreased inter-molar distance with vaulted palate
• Bruxism

As you are screening patients, it's important to note the gender differences in physical characteristics. For example, men typically display the anatomical traits of already-existing OSA—such as a wide uvula, large tonsils, and a high tongue—more often than women do. Conversely, women with large tonsils and a retrognathic profile are more likely to develop the condition.(10)

If any of these signs are observed, and you note other symptoms that may be indicative of sleep apnea (for example, if the patient is obese or complains of a dry mouth), you should ask follow-up questions, including:

• Do you snore?
• Do you frequently wake up at night with a gasp or choking sound?
• Are you often fatigued throughout the day?

Patients who confirm these symptoms should be further assessed. Although physicians are the only professionals licensed to diagnose OSA, dentists and dental hygienists can use screening tools for early detection of risk factors. If, after screening, you believe that a patient displays signs of sleep apnea, you should refer the patient to their primary care physician or a sleep specialist.

Screening tools available to hygienists

Two simple screening tools that can be easily used by dental professionals are the Mallampati examination and the Epworth Sleepiness Scale.

The Mallampati classification is used to assess the ease of intubation.(11) With the patient sitting upright and with their head in a neutral position, the patient opens their mouth. Patients are classified by the visibility of the soft palate. Patients with a high classification (3 or 4) should be sent to their primary physician for further evaluation.(12)

The Epworth Sleepiness Scale is a simple, self-administered questionnaire that evaluates daytime sleepiness. Patients who score greater than 10 are considered at risk for sleep apnea.(13)

Continuous positive airway pressure machine

CPAP is a commonly prescribed treatment for OSA and is effective in decreasing the number of apneas a patient experiences during the night.(14) The device emits a continuous stream of air that opens the airway and eliminates obstructions.

Research suggests that compliant patients show significant improvement in snoring and sleep quality, as well as a reduction in OSA’s associated comorbidities.(15) However, 8%-15% of patients prescribed the device refuse to continue use after one night of treatment, and 20% to 80% fail to adhere to treatment over the long-term, due to complaints of being uncomfortable during sleep as a result of the machine.(16) Without compliance to treatment, patients are left susceptible to the decreased quality of life that comes from a lack of restful, restorative sleep.

Oral appliances

When a patient is not compliant to CPAP or simply wants an alternative treatment option, oral appliances are often prescribed. These appliances look similar to a retainer or mouth guard, and are used to project the mandible forward, so that the tongue and soft palate don’t obstruct the airway during sleep. Prescribed and calibrated by specially trained dentists, oral appliances are a small, comfortable and non-invasive sleep apnea treatment. There are several oral appliances that can be used to treat sleep apnea, and an examination is required to determine which device is the most appropriate in fit and function for the patient.

Oral appliances are as effective as CPAP for mild to moderate OSA(17), and are overall more likely to be worn by sleep apnea sufferers. Patients self-reported that they wear their oral appliances an average of 77% of nights.(18)

As a dental hygienist, you have an increasingly prevalent role in the initial screening for OSA. By implementing the The Mallampati classification and the Epworth Sleepiness Scale into a dental exam, you can help in the early detection of OSA, as well as educate patients on the risk factors, symptoms and comorbidities surrounding sleep apnea. Patients can then be sent to a sleep specialist, such as a dental sleep medicine practitioner or sleep physician, for further assessment and treatment. With an estimated 80 percent of cases remaining undiagnosed, you have a pivotal opportunity to assist physicians in saving the lives of patients.

Dr. Jeff Rodgers is board certified in dental sleep medicine and has been treating patients for over 15 years. He serves as a Diplomate of both the American Board of Dental Sleep Medicine (ABDSM) and the American Sleep and Breathing Academy (ASBA). Dr. Rodgers works from his practice, Sleep Better, Georgia, in Dunwoody, Georgia.

References

1. Strauss SM, Alfano MC, Shelley D, Fulmer T. Identifying Unaddressed Systemic Health Conditions at Dental Visits: Patients Who Visited Dental Practices but Not General Health Care Providers in 2008. Am J Public Health.2012;102(2):253-255.
2. Young T, Peppard PE, Gottlieb DJ. Epidemiology of Obstructive Sleep Apnea.Am J Resp Crit Care. 2002;165:1217-1239.
3. Levendowski DJ, Morgan T, Montague J, Melzer V, Berka C, Westbrook PR. Prevalence of probable obstructive sleep apnea risk and severity in a population of dental patients. Sleep Breath. 2008;12:303-309.
4. Lee W, Nagubadi S, Kryger MH, Mokhlesi B. Epidemiology of Obstructive Sleep Apnea: a Population-based Perspective. Expert Rev Respir Med.2008;2(3):349-364.
5. Obstructive Sleep Apnea. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090.
6. "Understanding the Results." Healthy Sleep. February 11, 2011. http://healthysleep.med.harvard.edu/sleep-apnea/diagnosing-osa/understanding-results.
7. Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL. Obesity and Obstructive Sleep Apnea. Am Thoracic Soci. 2008;5:185-192.
8. Kandray, Diane P. "Screening for Obstructive Sleep Apnea." Dimensions of Dental Hygiene. April 2010. http://www.dimensionsofdentalhygiene.com/2010/04_April/Features/Screening_for_Obstructive_Sleep_Apnea.aspx.
9. Mulgrew AT, Nasvadi G, Butt A, et al. Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea. Thorax. 2008;63:536-541.
10. Dahlqvist J, Dahlqvist A, Marklund M, Berggren D, Stenlund H, Franklin KA. Physical findings in the upper airways related to obstructive sleep apnea in men and women. Acta Otolaryngol. 2007;127:623-630.
11. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Freiberger D, Liu PL. A clinical sign to predict tracheal intubation: a prospective study. Can Anesth Soc J.1985;32(4):429-434.
12. Hiremath AS, Hillman DR, James AL, Noffsinger WJ, Platt PR, Singer SL. Relationship between difficult tracheal Intubation and obstructive sleep apnea. Br J Anaesth. 1998; 80: 606-611.
13. Johns MW. A new method for measuring daytime sleepiness: the epworth sleepiness scale. Sleep. 1991;14:540-545.
14. Hoffstein V . Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath. 2007;11(1):1-22.
15. Mehta V, Subramanyam R, Shapiro CM, Chung F. Health effects of identifying patients with undiagnosed obstructive sleep apnea in the preoperative clinic: a follow-up study. J Can Anesthes. 2012;59:544-555.
16. Smith I, Lasserson TJ. Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003531. DOI: 10.1002/14651858.CD003531.pub3
17. Doff MH, Hoekema A, Wijkstra PJ, van der Hoeven JH, Huddleston Slater JJ, de Bont LG, Stegenga B, authors. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013 Sep 1; 36(9):1289-96.
18. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W, authors. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244–62.