The Dentist’s Role in the Obstructive Sleep Apnea Patient Pathway with Mayoor Patel

Sree Roy:

Hello and welcome. I’m Sree Roy with Sleep Review and I’m thrilled to be here with Mayoor Patel, DDS, MS, who is the owner of Atlanta-based Craniofacial Pain and Dental Sleep Center of Georgia and co-editor of the new textbook, Dental Sleep Medicine: A Clinical Guide. Today, we are chatting about the dentist’s role in the obstructive sleep apnea patient pathway. How did the book, Dental Sleep Medicine: A Clinical Guide, come about?

Dr. Mayoor Patel:

Sree, thank you for taking the time.

Yes, so this is interesting. We’ve been doing dental sleep medicine for over 10 years, and Gary and I have published other textbooks as well. What we found was there was this lack of uniformity when it came to information with dental sleep medicine.

There’s three great books already out there. One’s Dental Management of Sleep Disorders by Dennis Bailey, which I believe is in its second edition. The Clinical Handbook for Dental Sleep Medicine when Ken Berley and Steve Carstensen, which is a very well-written book as well. And the other one by Dr. Lavigne, which is Sleep Medicine for Dentists, which is also in its second edition. These are books we refer to and reference when we were going through our pathway as far as doing dental sleep medicine. And teaching over a course of time, we heard different soundbites, “I didn’t get this in this book” or “I didn’t understand this concept.”

And when COVID hit, we were just at home doing nothing. And Gary calls me up one day and is like, “Hey, the book you want to write, maybe it’s time to write it.” So April 2020 is when we sat down and basically started finding the people who would write specific chapters, came up with the idea of what people wanted, and put this textbook together, breaking down from clinical signs and science to tie the two together so there’s a better flow of understanding the topic of dental sleep medicine.

And what we found this textbook evolved into is what we feel may be the textbook that will be used in dental education now that dental schools are hopefully teaching this topic, and become a resource for information. So it’s basically COVID, which a lot of good projects have started off, and it’s finally completed.

Sree Roy:

Well, congratulations on completing it. You mentioned Gary a few times. You want to just give a quick shout out to the other editors of the book and their names?

Dr. Mayoor Patel:

Yes. Yeah, sure. So Gary Demerjian is a colleague of mine in Los Angeles. He has a very similar practice to mine, [inaudible 00:02:36] with joint disorders or facial pain and dental sleep medicine. Francisco and Andrea were both at UCLA. I believe Francisco is now retired. Andrea is still doing clinical research. And the four of us collaborated to get this textbook out to print.

Sree Roy:

Excellent. Why should dentists have a basic knowledge of sleep medicine?

Dr. Mayoor Patel:

Yeah, this is great. I mean, if we think about the field itself, and if we go back in time, a lot of the old time dentists that were treating TMJ disorders were using these splints that had these ramps built into it. They were called for all appliances. And what they had found was interesting is these patients would complain of snoring or complain of being fatigued, but coming in for pain and wearing these mouth guards, it improved not just pain, but also their subjective symptoms of sleep complaints.

So you can see that dentistry plays an integral role when it comes to possibly addressing these patients. So as dentists, I feel that we have devices that we can utilize and they’ve been around since the 1980s, to help manage these patients that have these conditions. But ultimately, we have the opportunity in seeing these patients twice a year for the regular checkups and cleanings, we have the ability to look over the health history forms, we have the ability to look at the upper airway, and I feel that the lack of understanding of what we see in the upper airway and identifying these patients may be why it gets missed.

But now in dentistry being that dental sleep medicine seems to be a hot topic, a lot of us can be involved, purely from the fact that we are sitting on populations of patients that need to be screened, if not educated and better yet, managed.

Sree Roy:

What are some of the most common medical comorbidities of obstructive sleep apnea?

Dr. Mayoor Patel:

Yeah, so I mean the big ones that come out there that we can talk about is cardiovascular diseases. And when we look at cardiovascular diseases, we’ll see like hypertensive patients, 37% of that population have sleep apnea. Those that are taking more than two blood pressure medications, drug-resistant hypertensive patients, roughly 83% of that patient population has apnea. If we look at like congestive heart failure, 60% of those patients are dealing with this condition. Those that have had a stroke or had a transient ischemic attack, maybe 70% of them are dealing with this as well. Coronary artery disease ran about 30% of those patients having it. Cardiologists are now looking at arrhythmias and if patients have arrhythmias before they would just burn those lesions, now they’re actually make referrals to assess whether or not there is a sleep component. I think the literature points to about 88% have a good prevalence of having sleep apnea, those that have arrhythmias.

Let’s not forget insomniacs. There’s a lot of insomniacs that have a hard time maintaining sleep. Anywhere between, I think, 40 and 60% of those patients may have obstructed sleep apnea.

So we know that there’s a lot of medical comorbidities that we do see. Even diabetics, there’s this beautiful review paper looking at five different studies and they conclude that almost 70% of diabetics potentially have sleep apnea. A recent paper on asthma showed about 50% of asthmatic adults having sleep apnea. And of course GERD being the other as well.

So there’s a lot of comorbidities in medicine that before were being treated as isolated conditions, but some of them may have a common denominator where maybe sleep apnea needs to be assessed or some form of sleep breathing disorder needs to be assessed. And if so, then possibly manage to get better outcomes with these medical comorbidities that these patients deal with. So I’m glad that the literature’s showing this. I’m glad more and more work is being done, but our textbook has an extensive chapter dedicated to these comorbidities to make us more aware of what these are, and I’m just highlighting a few here.

Sree Roy:

What about the common dental comorbidities of obstructive sleep apnea?

Dr. Mayoor Patel:

Yeah, I mean that’s a good one too. From a dentistry standpoint, if you start off with pediatrics, mouth breathing. Basically nasal congestion, nasal airway issues leading to mouth breathing, which leads to poorer maxillofacial development, which also therefore increases the potential risk for sleep breathing disorders later in life. But as a result of mouth breathing, underdeveloped maxillos, you’ll find that vaulted palate is also a dental comorbidity associated with it.

When we look at the tongue, we do our oral cancer screening as an example. We look at the lateral borders of our tongue just to make sure there’s no cancer. But interesting, the lateral borders, you’ll see scalloping of the tongue or a large tongue or a high Mallampati score, strongly suggestive that there may be an airway issue that needs to be taken a look at. Attrition, wearing down of teeth, possibly due to bruxism. But there again, understanding that many things can cause bruxism. One may be an airway component associated with it. In patients we might find extra bone growth such as toris on the bottom jaw, exostosis on the upper jaw or the lower jaw, strongly suggestive of maybe parafunctional reasons.

So there’s a lot of things in dentistry that we see clinically that we may fix and manage but not actually realize that there may be an underlying sleep issue that could be sought out for and maybe if identified in these patients managed appropriately. And these are some of the comorbidities that we would see in a typical dental practice.

Sree Roy:

How can dentists learn to conduct a basic screening for obstructive sleep apnea? Is this something they can learn from articles or books or do they need to take an in-person class?

Dr. Mayoor Patel:

Yeah, that’s a great question, actually. It’s funny, in October 2017, the ADA put out a statement saying that dentists should be screening for airway issues, which is interesting that they bring out that statement. Now, of course it’s going to take a minute before schools catch up. But the fact that dentistry is now being put in the forefront, at least screen for these conditions makes a lot of sense.

I think to your point, classes are basically a good way to start if you’ve not had any exposure to it. I think dental education’s getting there, but for those of us that have graduated, taking some course and understanding what this might look like.

Implementation for a screening might be concerned that you can do immediately would be questionnaires, Epworth Sleepiness Scale being one. The other one I think that may be a little bit more robust will be the STOP-Bang Questionnaire. And using questionnaires to basically get a sense of how at risk your patients might be, may not be a bad thing.

The medical history form, as I outlined when we talked about the medical comorbidities, you are looking at your patient’s health history and getting a snapshot if they’re diabetic, hypertensive, things of that sort, which also tip the scale to suspicion that they may have an airway issue.

So I think yes, taking maybe some form of a course, definitely brushing up on the literature, and implementing some form of paperwork or questionnaires to start screening these patients would be a good way to go.

Sree Roy:

That’s good advice for how to get started. For those who aren’t aware that dentists can provide therapy for obstructive sleep apnea, can you clue our audience in as to how oral appliance therapy works?

Dr. Mayoor Patel:

Yes, sure. So the beautiful thing is if we look at it from the standpoint that if the tongue’s the culprit… And there again, understanding that upper airway issues does not have to be at one level, it could be the tongue, it could be the soft palate, it could be the nasal, it could be a combination of all three or any combination as of sort.

If it’s tongue based, the fact that the tongue is attached to the mandible makes total sense that if we take the lower jaw forward, we have the opportunity to bring the tongue forward. And by doing so, we open up the oropharynx by holding the jaw forward using mouthpieces, which is what a dentist would do, we can basically stabilize the tongue to the point that we can keep a patent airway so the individual can breathe through their nose without any obstructions taking place and therefore not having sleep apnea or in some cases also improving snoring.

I do just want to make a note of caution that if we do go down this road of doing mouthpieces or oral appliances, we should be mindful that these patients need to be diagnosed by a physician first and not by a dentist. Our role purely is to manage these patients using oral appliances by prescription that is provided by the medical doctors. So we do have a role in this, but we need to understand that our limitation is to manage them with oral appliances once an appropriate diagnosis has been made by a medical practitioner.

Sree Roy:

Thanks for clarifying that. And where can our audience find you online and find the book? Dental Sleep Medicine: A Clinical Guide?

Dr. Mayoor Patel:

Yeah, so as far as I’m concerned, we do provide courses. If you look at benpatinstitute.com, there’s a list of courses that we provide throughout the year. The other resource, as far as the book is concerned, right now Amazon has the book available, but if you go to springer.com and you search for the book, there is the electronic version and the print version also available. So you got Springer that you can get the book from, which is the publisher of the textbook, along with Amazon presently.

Sree Roy:

Excellent. Well thank you so much for chatting with us about dental sleep medicine today, and you can find Sleep Review at sleepreviewmag.com. Thank you so much for tuning into this episode.