Debbie Blenis doesn’t know yet if she has obstructive sleep apnea, but the Palm Bay woman knows all about the subject.
“My father has sleep apnea, and I understand what that can be like,” she said. “When he finally saw the doctor about it ... he was told he was a stroke waiting to happen.”
So, knowing sleep apnea runs in her family, aware of the dangers and already possessed of two of its classic symptoms, bruxism (grinding of the teeth) and snoring, she has agreed to be tested for the condition by her dentist, Dr. Lori Nelson of Ultimate Smile Design in Palm Bay.
Nelson and other dentists screen, and now, collaborating with sleep medicine specialists, treat patients for the potentially life-threatening disorder that causes breathing to stop during sleep.
So important is the subject to dentistry that the American Academy of Dental Sleep Medicine, a nonprofit professional society founded in 1991, has more than 2,800 members nationwide and is growing. It and other professional organizations, including the American Dental Association, now offer courses to better acquaint dentists with sleep medicine.
Last year, Dr. Gail Demko, president of AADSM and expert adviser to the Food & Drug Administration in oral appliance therapy, told the publication Dentistry IQ(dentistryiq.com) that dentists are particularly well-equipped to handle “sleep-disordered breathing.”
Once, sleep medicine was strictly the province of specialist physicians who tested and treated apnea and related conditions, often prescribing use of sometimes-cumbersome continuous positive airway pressure devices, which use mild air pressure to keep airways open while patients are sleeping. It involves wearing a mask or other device that fits over the nose and mouth, which is connected by tube to a machine that blows air into the airways.
Patients determined by their physicians to have severe cases of apnea still are prescribed CPAP treatment, but a patient with mild to moderate sleep apnea now may be fitted by his or her dentist with a small, custom-fitted, mouth guardlike appliance that maintains an open, unobstructed airway during sleep.
“The device, which is worn while sleeping, repositions the mandible (lower jaw), so that the airway remains open,” said Nelson, who has practiced dental sleep medicine since 2006.
But it is not simply a matter of fitting a mouthpiece. Potential wearers must first undergo testing and studies, and the dentist’s work is done in conjunction with the doctor’s.
“The important thing to convey is that a dentist cannot treat these conditions alone,” said Dr. Duongvannak Keo, who practices dentistry on Merritt Island. “We’re not allowed to diagnose sleep apnea, we only screen our patients for it. Then, we can treat them based on a physician’s referral and recommendation.”
But dentists, because of their training and the very nature of their profession, do notice the signs.
“The clinical aspect of treating sleep-disordered breathing, be it snoring or sleep apnea, requires basic skills that have been taught to dentists in their restorative dental training. The most important aspect is the academic knowledge required to become part of a team that is treating a medical disease,” Demko said.
It is less a procedure than a process, dentists add.
“We are looking for signs of dental disease, no doubt, but we’re also looking at a patient’s bite and its possible effect on his or her overall health,” Nelson said.
That means questions about sleeping habits as well as teeth.
Nelson said that when a patient reports he or she is not sleeping well, the Epworth Sleepiness Scale, which measures daytime sleepiness by asking a patient to rate his or her likelihood of falling asleep, is used at Ultimate Smile Design, followed by checks of oral and nasal airways.
“If we see something that possibly indicates sleep apnea, we will order a sleep study, coordinated with the patient and his or her physician,” she said.
Keo agreed: “We guide them through the process and refer them to a sleep physician.”
Only after mild to moderate sleep apnea is diagnosed will the dentist recommend the new device.
“A pharyngometer is used to measure the pharyngeal airway size to assess the patient for obstruction, so when the patient is fitted, (the jaw) is in a scientifically specified position,” Nelson said. “And we do confirm things with another sleep study, which we have read by a certified sleep medicine physician.”
Thus, physicians and others who work with sleep apnea patients in the traditional, medical setting say they welcome the involvement of dentists, who may be the first practitioners to notice potential problems
“We work primarily with Dr. Keo, who is certified (in dental sleep medicine and oral appliance therapy),” said Kristina Weaver, sleep center supervisor for Parrish Medical Center in Port St. John. “We will do a sleep consultation and a sleep study, and if the patient has mild sleep apnea, he does the consultation. He makes the mold, and he fits the patient with the device.”
Patients should not expect, however, that the dental device will work on all sleep apnea patients.
“These devices are intended primarily for people with mild sleep apnea,” Weaver said. “The CPAP still is always the first alternative, because we know without a doubt that it will correct the problem. (The mouthpiece) is not as good as the CPAP, but if the apnea is mild, it may help.”
Keo, who estimates he has made about 100 oral appliances for sleep apnea patients, called them “devices for people who cannot tolerate CPAPs; people who are looking for alternatives,” and referred to the CPAP as “the gold standard.”
Furthermore, dentists who screen patients for possible sleep apnea are by no means attempting to usurp anything from physicians.
“We tell every physician, ‘Look, I’m not taking your patient, I’m just screening for problems that you can help with. I’m not taking your patients, I’m giving you patients.’ ”
Most physicians don’t realize that such appliances even exist, he added, and so the dentist becomes a source of information as well.
“I think this is the way of the future,” Nelson said. “This is where medicine and dentistry are headed: working together for the good of our patients.
Blenis couldn’t agree more.
“I absolutely think sleep apnea is life-threatening,” she said. “It’s easy to ignore, especially if you don’t sleep with a partner who would notice that you are snoring loudly, or that your breathing has stopped. ... I feel a lot of comfort in that my dentist is watching out for my overall health and not just my teeth.”
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