Podcast: What dentists need to know about sleep medicine

Hello and welcome to Ascent Dental Radio. A program dedicated to the balance between the clinical aspect of health care and the business of health care. And now here is your host, Dr. Kevin Coughlin.

Welcome. You’re listening to Ascent Radio. This is Dr. Kevin Coughlin. You can hear this podcast on Ascent-Dental-Solutions, where the focus is on knowledge, development, training and education. Today’s podcast is for dentists and for the lay public that is interested in learning more about sleep medicine. I want to first, before I get started, give a congratulations and a big thank you to Mr. Doug Foresta. His company, Stand Out and Be Heard, has produced over 30 of these dental podcasts for me and the production and the effort is tremendous. Thank you so much, Doug.

My name is Dr. Kevin Coughlin and this is Ascent Radio. Today, the topic is sleep medicine. Sleep medicine started back in 1895. So it is not new, but it is new to the dental profession. And it appears to me that each year sleep medicine is becoming more and more important, not only for the dental facilities to provide care and service in this area, but for the public to be informed.

Some statistics that may shock us; number one, sleep disorders are more common than asthma and diabetes combined. This means that it is affecting tens of millions of people. You may not be aware of it, but 20 percent of all motor vehicle accidents are associated because of sleep deprivation. The driver is tired, they’re not alert and there’s a motor vehicle accident.

Some notable issues that were associated with sleep deprivation were the Three Mile Island plant that almost blew up, the Challenger, which did blow up. All of these events and in particular motor vehicle and truck accidents, occur between the hours of 1:00 am and 7:00 am. And this is because tens of millions of people are not getting the proper amount of sleep.

Some systemic issues that are associated with sleep deprivation are hypertension or high blood pressure, stroke, dementia, loss of memory, loss of alertness, a decrease in memory, a decrease in alertness. All of these factors have an effect on our ability to perform at a high level and feel good about our overall health.

How does this relate to dentistry? First of all, the American Association of Sleep Medicine is considered the governing body. It provides guidelines and the standard of care for dentists and physicians to follow to provide the public with the highest level of education and with the proper processes and procedures to help our population address this chronic, severe problem of sleep deprivation.

In lay terms, most people consider going to a dentist for snoring. Their significant other is disturbed and irritated because the individual snores and that snoring creates a situation which is uncomfortable and embarrassing.

In reality, the proper process and procedures to provide excellent care in sleep medicine is the following; first and foremost, you should seek out a dentist that either has certification, designation or a minimum of 25 hours of training in the appropriate sleep medicine courses.

Many dentists provide sleep medicine care and treatment, but most do not have the designation, the certification or the minimum requirements and as a lay person, you may want to seek out those qualifications. This certainly doesn’t mean that a dentist that doesn’t have these qualifications can’t provide adequate care and service, but first and foremost, you may want to consider those three options in choosing a dentist to provide this care.

The next thing to look at is how is sleep dentistry provided today in the United States. Many times, there’s confusion and the lack of ideal care and service. Step one, according to the American Academy of Sleep Medicine is the patient must have what is called a PSG, or a polysomnogram. This is a level one sleep study done in an area hospital where the individual stays overnight and their eye movement, muscle movement and cardiac evaluation is constantly monitored along with their blood pressure, their inspiration, expiration and a combination of all these factors will determine whether the correct diagnosis of obstructive sleep apnea is present or not present.

By definition, obstructive sleep apnea is determined by the number of times an individual stops breathing during their nighttime sleep. As a general rule, between zero and five is considered normal, between five and 15 is considered mild obstructive sleep apnea, between 15 and 30 is considered moderate obstructive sleep apnea and above 30 to 60 episodes is considered severe. It’s critical that this proper diagnosis be made.

In most cases, this is going to be done by a physician in a sleep facility and in most cases, it will be covered by your medical insurance and in most cases, the gold standard of treatment at present time is called CPAP, which stands for Continuous Positive Airway Pressure. In 2017, the C has been dropped and now the correct verbiage would be PAP or Positive Airway Pressure because some of the newer CPAP machines do not provide continuous positive airway pressure, but it comes intermittently and some patients respond better.

It is critical for the lay and professional individuals to make a proper diagnosis of obstructive sleep apnea. If in actuality you do have this condition, this condition can be life-threatening. It can increase your chances of stroke, hypertension, diabetes, memory loss, physical activity, concentration and alertness along with a decrease in your autoimmune or your ability to fight diseases. I bring this up because many times we as dentists will simply treat the patient for a snoring disorder. In order to follow the appropriate guidelines by the American Association of Sleep Medicine, you shouldn’t be taking that course of action, in my opinion, and in many others in this field.

Step one is make sure the PSG study is done. Once you’ve been diagnosed, the gold standard, as discussed earlier, is the CPAP unit. However, 80 to 85 percent of the public are unable to tolerate the CPAP unit. They find it constrictive, some people feel claustrophobic, people find it difficult to sleep. Generally, most people have the most difficult time during their first seven to 14 days. If you can get by those seven to 14 days, usually, most people adapt and they’re quite comfortable with the CPAP unit. However, the vast majority of patients don’t make it those 14 days and are looking for alternatives. And those alternatives from a dental standpoint, in most cases, are what we call Intraoral Devices or Mandibular Advancement Devices. Mandible standing for the lower jaw.

There are an entire slew of perhaps 75 intraoral appliances and they all have advantages and disadvantages. But in sum and substance, the major driving force is the appliances should be comfortable. They should fit well. They should be able to advance your lower jaw in increments of one millimeter or more. They should be easily adapted and changed based on your particular needs.

I’m not going to waste time and energy going through each individual device, but suffice it to say that the intraoral appliance many times could act and provide as much success in obstructive sleep apnea as the CPAP unit when it comes to mild and moderate cases of obstructive sleep apnea.

For those individuals who have severe obstructive sleep apnea, the gold standard is still the CPAP unit. However, for those patients who can’t tolerate it or refuse to use it, they’re still much better off with an intraoral appliance. Keep in mind that these intraoral appliances should last at least three years or longer. In most cases, the fees will range anywhere from $800 to $2,200. The reason for the vast variety of fees depends on the type of appliance and whether the adjustment visits are associated with the overall cost of the appliance.

In most cases, the correct process and procedure is the dentist will deliver the intraoral appliance. It’s first constructed by impressions of the top and bottom jaw. Those impressions are done in the dental office and then a construction bite is taken with the lower jaw in a protrusive or forward position. Generally, the upper and lower teeth are separated between two and five millimeters. And generally within seven to 14 days, the appliance is fabricated either in the dental office or at a professional dental laboratory.

The device is then delivered to the patient, and in most cases, the patient should be seen within seven to ten days to make any additional adjustments to make sure that the patient is comfortable.

Common complaints with the intraoral appliance are that patients will state that their teeth are a little sore in the morning. Their temporomandibular joints may be a little uncomfortable from the protrusive force placed on by the appliances. Overall, the results tend to be good to excellent, but keep in mind the subjective findings are not good enough according to meet the standard of care.

After the adjustments to the appliance have been made and the patient feels more rested, more comfortable and their significant other states that they hear less snoring or no snoring at all, the correct process and procedure is to have a follow-up PSG examination so that we can look at the objective studies and determine ocular movement, which is an EOG, muscular movement which is an EMG, and brain waves and cardiac issues which are an ECG or an EKG. The reason for this is we’re looking for objective evaluations to determine that the intraoral appliance is providing the high level of care and service to improve your overall health.

Keep in mind that there’s nothing that will make you feel better than a good night sleep. We’ve been providing intraoral appliances for sleep disorders for many years now and it is amazing to me how much better patients state they feel, how much better and more alert they are after the use of an intraoral appliance or a CPAP unit.

Keep in mind that there are some specific things that can be done to reduce your need for each of these devices. Number one for a female, you should try to keep the diameter of your neck less than 14 inches. For a male, less than 17 inches. Your base body mass index should be less than 30.

Losing five to ten percent of your body weight will significantly improve or reduce the need for an intraoral device or an extra-oral device. These are things that really can not only improve your overall health, but reduce or eliminate the snoring.

Keep in mind that all patients that are diagnosed with obstructive sleep apnea they all snore, but all people who snore do not have obstructive sleep apnea. By definition, apnea simply means the sensation and lack of breathing for a duration of five to ten seconds or longer. They are significantly different than a snoring event and that’s why the correct diagnosis is imperative.

Keep in mind that this information, along with other information, will be brought to you in future podcasts. For those individuals that are suffering from snoring, in summary, get the proper diagnosis first and then if the CPAP is effective, go forward and if it is not, consider seeing your dentist who has certification, designation or a minimum requirement of 25 hours or more in continuing education devoted strictly to sleep medicine.

A simple trick for our listeners to determine whether an intraoral device would be effective at eliminating or reducing snoring is as follows; make the snore sound. Just sitting in your car right now or sitting at home, make that snore sound [snores] now take your lower jaw and move it forward as far as you can and attempt to make that same sound and you’ll find that if you can, then more than likely, the intraoral appliance is the root to go and you will have an effective and successful result and save yourself thousands of dollars and hours of time. I</span

t’s a simple trick that most of us can us at home. And the reason I explain it this way is sometimes snoring and sleep apnea is caused by an upper airway or nasal passage obstruction. When that’s the case, an intraoral appliance would be much less effective or not effective at all.

Another cause of sleep apnea or snoring is some kind of central nervous system disorder. And again, in most cases, an intraoral appliance will not be effective. However, overall, over 90 percent of all sleep apnea or obstructive sleep apnea is caused by occlusion of the oral cavity or back of the throat by the tongue. By bringing the lower jaw or mandible forward, the tongue is advanced forward and the airway is open.

I hope you’ve enjoyed today’s podcast. You’ve been listening to Dr. Kevin Coughlin and this is Ascent Radio and you could get more information on my website www.ascent-dental-solutions.com.

And again, my thanks to Stand Out and Be Heard, Mr. Doug Foresta, who’s produced this podcast. Thanks again and I look forward to talking to you soon.