Patients with sleep-disordered breathing can benefit from education, interdisciplinary communication, and awareness.
The explosive growth in both the public’s and medical community’s awareness of the dangers associated with sleep-disordered breathing (SDB) is placing an enormous burden on the resources available to diagnose and treat these patients. (How long is the wait for a sleep study at your facility?) As science unravels the mysteries of sleep, we find potential correlations to many medical conditions involving nearly every medical specialty and discipline. The relationship between SDB and cardiovascular morbidity and mortality alone, if universally recognized, could bankrupt the system. When we search literature, we find SDB being investigated as a cause and/or contributing factor for conditions such as stroke, heart attack, depression, diabetes, headache, cognitive dysfunction, memory loss, kidney disease, asthma, gastroesophogeal reflux disease (GERD), chronic fatigue, fibromyalgia, impotence, and attention deficit hyperactivity disorder. I believe you are what you eat and how you sleep. We need three things to survive: good nutrition, sleep, and oxygen. It seems logical that SDB, which compromises the quality if not the quantity of both sleep and oxygen, should have such an impact on our overall well-being. Why would we spend nearly 1¼3 of our lives in this state if it did not account for more than we are giving it credit for. If not, what a waste of time sleep would be.
I believe that SDB is a long-term, progressive, broad-spectrum entity, beginning with benign snoring progressing to upper airway resistance syndrome (UARS) and culminating with obstructive sleep apnea (OSA). I do not believe there is such a thing as benign snoring, especially if you consider the people who live with these so-called benign entities. What if time and good science prove that many of the conditions now being studied have an origin in sleep? Imagine the potential to practice preventive medicine. For example, antihypertensive medication does not cure the problem it treats or control a condition that may be a symptom of SDB; heartburn medications do the same thing in that they treat a symptom, not the cause. I have never known a patient to be cured of hypertension or heartburn by taking medication. I do not pick these examples lightly; it is well established that in many patients these conditions improve with continuous positive airway pressure (CPAP) therapy. If these relationships are shown, health care providers will have to do a much better job of communicating and working together than we do now.
My experience in the 10 years I have been treating, teaching, and researching sleep problems has allowed me to interact and work with many talented individuals. Ten years does not sound like a long time, but for a dentist it qualifies me as a pioneer. I have a unique perspective in that for years I treated patients only after they had run the gamut of well-intentioned souls before me; things are different now as I am no longer considered the “last resort.” Patients enter the system through many doors, most often referred by their primary care physician in part due to insurance issues, next most often by the various medical specialties, ie, otolaryngology, neurology, pulmonology, and dentistry.
Once suspected, the diagnosis of SDB in most cases is relatively straightforward. I believe, however, that we are extremely gender- and obesity-biased, causing us to shortchange many patients. Nearly half of my patients are women and most of my patients do not have a weight problem. You will notice that while I use the term “sleep-disordered breathing” universally, I think we need to consider that no matter what we call it or how we quantify it, the treatment options basically remain the same. The patient with UARS who does not desaturate significantly, but has severely fragmented sleep secondary to respiratory effort-related arousals, is just as deserving of treatment as the severe OSA patient. The different labels only create confusion and certainly chaos when it comes to insurance reimbursement. What if we had universally agreed-on diagnostic criteria, terminology, and technology that could determine with accuracy and certainty which therapy would be best for whom? We do not, so we accept the fact that our treatments are both diagnostic and therapeutic and learn by trial and error.
Sleep specialists do an admirable job of diagnosing and quantifying the patient’s condition; however, all too often they are not involved in the treatment and follow-up of the patient. Sleep laboratories are becoming diagnostic centers as sleep studies are faxed back to referring doctors whose treatment approaches most likely reflect their specialty. Or the patient is placed in the capable hands of a respiratory therapist who is given the daunting task of making CPAP therapy work, sometimes in a split-night situation and almost always without adequate time to introduce and prepare the patient for the experience, let alone do proper follow-up. This is not a criticism, only an observation.
In my opinion it is the sleep technicians and respiratory therapists who are the foundation of this field, without whom the rest of us would be unable to function. They do difficult jobs under stressful conditions. (When was the last time you pulled an all-nighter?) They deserve our admiration and appreciation. Ironically, we contribute to the sleep disorder quandary by adding to the sleep problems of the people trying to help those with SDB. What if we could develop an accurate daytime evaluation for SDB?
There is a reason CPAP is still considered by many to be the gold standard; when tolerated, it does the job. However, if we consider the latest compliance studies, we appreciate the importance and need for adjunctive, combination, and alternative therapies.
Nowhere is the adage “necessity is the mother of invention” better demonstrated than in the field of SDB. We have hundreds of different options: machines, surgeries, and devices all attempting to solve the SDB problems of million of sufferers. The following are examples of possible solutions:
Pulmonary medicine—CPAP, bilevel, ramping, humidification, bubble masks, gel masks, and 50 other types of masks, nasal pillows, headgear, and chin straps.
Otolaryngology—uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, tonsillectomy, turbinate and septal surgeries, somnoplasty, polyp removal, and adenoidectomy.
Maxillofacial surgery—hyoid suspension, maxillomandibular advancement, distraction osteogenesis, staged surgical procedures, tongue reduction, and genial advancement.
Over-the-counter remedies—nasal drops, nasal sprays, herbal remedies, positional trainers, nasal strips, and pillows.
Dentistry—at least 30 different oral appliances, mandibular advancement devices, tongue-retaining devices, orally delivered positive airway pressure devices, orthodontic intervention, and custom respiratory interfaces.
The number of possible solutions is both confusing and overwhelming to me, and I can only imagine how patients must feel when they are presented with just a few of these options. I think it is agreed that there is no one solution to the problem. All of these gadgets and procedures exist because at some time they were found to have merit and benefited the patient. We are not a one-size-fits-all organism and we must tailor our treatments to the patients’ desires, needs, and ability to successfully tolerate or use whichever methods are chosen. Additionally, with the exception of weight loss and some surgical procedures, everything else is a treatment, not a cure. This means that we must develop protocols and methods to help ensure the patient’s successful use of whatever therapy is rendered.
No matter how you look at it, SDB is about upper airway development and collapsibility, and each solution shares a common goal of decreasing airway collapsibility. What if sleep centers used a multidisciplinary approach with all specialties represented? Sleep specialists, whether they are involved in the pulmonary, neurologic, internal medicine, or psychiatric component, could quarterback by handling the diagnostics and, when appropriate, respiratory therapies. I would want a surgical team with both otolaryngology and oral surgery represented to provide treatment in cases of obvious correctable anatomical abnormalities. (You cannot use CPAP on a patient who has limited nasal patency due to a deviated septum, allergies, and turbinates). Children and adults who present with skeletal abnormalities can benefit from what the maxillofacial surgeons can offer. Dietitians and psychologists could offer counseling and support when appropriate. This is not a complete list as every medical discipline has something to offer.
Dentistry and Sleep
Finally allow me to offer some thoughts regarding my specialty. A dental component to the sleep team is a relatively new concept, but one whose time has come. We are fortunate to have long-term relationships with our patients with regular timely visits, allowing us to monitor and intercept problems in the early stages.
The “Position Paper on Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances,” presented by the American Academy of Sleep Medicine in 1995, stated that oral appliances were appropriate for snoring, mild cases of apnea, CPAP, and surgically intolerant moderate and severe cases. This resulted in an expansion of the science of dentistry to include sleep medicine. A dentist trained in the field of dental sleep medicine can be a valuable addition to the treatment team. Legally, we are not trained or licensed to diagnose sleep disorders; however, much in the same way that we screen for oral and facial cancer, dentists can help screen for patients with SDB, making the appropriate referral to the sleep laboratory when indicated.
The more recent titratable oral appliances have been shown to be effective even in moderate and severe cases of SDB and when compliance is factored into the equation, the argument for oral appliances gets stronger. Studies show that when given a choice, patients prefer oral appliance therapy (OAT) versus CPAP. Although there are some side effects with OAT, they appear to be insignificant when weighed against the benefits they can effect. Improved technology and increased awareness have resulted in our seeing more patients earlier in the game with conditions in the mild to moderate range. This being the venue where OAT seems to shine, there is no good reason for not having a dental component on the team.
What if we had better interdisciplinary communication, better education of the patients and ourselves, as to be more aware of all the options? What if we had universal evaluation criteria and terminology, diagnostic and treatment predictors, and worked in conjunction with one another rather than independently? What if we listened better to our patients and considered their needs and preferences? What if we opened our minds and realized that this could be just the tip of the iceberg as we witness and hopefully participate in the elevation of the field of sleep to the forefront of preventive medicine? What if ?
Don A. Pantino, DDS, is president of the Academy of Dental Sleep Medicine and serves as a dental consultant to several sleep centers in Long Island, NY.