The dentist's place in sleep medicine
Over the last 10 years, we have seen an explosion of information when it comes to sleep apnea. We now know that if left untreated, sleep apnea is a major cause of heart attack, stroke, hypertension, and diabetes. Several recent studies have also linked sleep apnea to cancer and aging. Dr. Robert S. Rosenberg talks about how important it is for dental professionals to seek training in this growing area of sleep medicine and establish a good relationship with the sleep lab.
The problem we sleep specialists face is that although we have a very effective treatment — CPAP — only about 65% of our patients can tolerate it when followed over the course of a year. As a result, oral appliances have become the best alternative available.
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Most studies have shown that oral appliances are most effective when we dealing with mild to moderate sleep apnea, which is defined by an apnea-hypopnea index of between five and 29 events per hour. Still, there are many examples of the appliances working even in severe sleep apnea. In fact, Medicare will approve an oral appliance, even in severe sleep apnea, if the patient cannot tolerate CPAP.
The problem has been an inability to predict who will benefit from these oral appliances. However, to quote Bob Dylan, “The times they are a-changin’.” There are now devices that can help predict the efficacy of these appliances before they are made. In fact, one such study will be published next month in the Journal of Clinical Sleep Medicine. Additionally, we now have the ability to further advance these devices in the sleep laboratory. As an example, my sleep techs commonly turn an unsuccessful titration into a successful one with a few turns, the referring dentist having provided them with advancement parameters.
Therefore, the take-home message is that the field of dental sleep medicine is alive and well. I would advise dentists who are interested in this field to seek training. Then I would recommend that you let the sleep specialists in your community know what you can offer them and their patients. When new advances in oral appliance therapies are made, bring it to their attention. Do not take for granted that we are as well informed about these matters as you. In fact, in my own case I have learned a great deal from my dental colleagues who either call or visit my sleep center. In some cases, they have sent me copies of studies that have appeared in their journals, which I greatly appreciate.
Finally, take the time to develop a relationship with a sleep lab, its medical director, and technicians. If you want the night technicians to be able to foster oral appliances, develop a written protocol. Also, plan to meet with them and the clinical director to go over these protocols and show them how to accomplish this in the lab. Believe me, your active participation makes our jobs much easier, and we will more likely refer our patients to you. It also leads to greater patient satisfaction, as there is nothing I like less than to have to send out an oral appliance report stating that the appliance was ineffective when a few simple in-lab adjustments could have made a major difference.
Robert S. Rosenberg, DO, FCCP, is the medical director of the Sleep Disorders Center of Prescott Valley, Arizona, a sleep medicine consultant for Mountain Heart Health Services in Flagstaff, Arizona, and is board certified in sleep medicine, pulmonary medicine, and internal medicine. He is a contributing sleep expert blogger at EverydayHealth.com and his advice has appeared in O, The Oprah Magazine, Women’s Health, Prevention, Ladies’ Home Journal, and Parenting, among others. Visit his website at www.AnswersForSleep.com.