Dentist Evaluation

What the Dentist Can Do for Obstructive Sleep Apnea

Today Dentistry is called on to do much more and to be familiar with health care issues of their patients and not just of their dental and oral health status.  It was just recently that Dentistry incorporated taking blood pressure at dental visits. When the blood pressure was high, the patient was directed to contact their physician and have this evaluated more thoroughly. This increased awareness led to the recognition of many people who were at risk for hypertension and who otherwise would have been undetected.

More recently, the association between cardiovascular disease and periodontal disease has been identified, and more aggressive steps are being taken clinically to resolve the periodontal condition in order to reduce the risk for cardiovascular disease.  Furthermore, oral cancer screening is another action that the dentist performs during the initial and follow-up care visits.  Other instances are related to the recognition of oral conditions associated with systemic illnesses such as diabetes, leukemia, and many of the autoimmune diseases (e.g., Sjogren’s syndrome).

Obstructive sleep apnea (OSA) screening is another area the modern dentist can perform.  OSA can impair one’s quality of life and daily performance relative to driving, school performance, relationships, work efficiency or operating any other machinery.

The role of the dentist in the recognition of patients at risk for OSA and other sleep-related breathing disorders (SRBD), such as snoring, is now well recognized.  The dentist is just as likely to identify a patient who is at risk for OSA as is the physician.

WHAT THE DENTIST SEES THAT INDIVATES THE RISK FOR SRBD

The dentist and the dental hygienist see patients regularly who have signs of SRBD.  Yet, unless they are familiar with and recognizes the potential signs for SRBD, the sleep disorder may go undetected.  However, these finding of SRBD must be evaluated on their own merit.

When any signs or symptoms are recognized, the dental provider must:

• Determine if the risk for snoring or OSA is present
• Inform the patient of the findings
• Consult with them regarding the appropriate measures needed for a complete diagnosis and management plan

Conditions that indicate the risk for a sleep-related breathing disorder: sleep apnea and snoring

The basic questions that the dentist should include in the initial patient history form are the following:

• Have you ever had a sleep test? Has your doctor recommended a sleep test?
• Do you or have you been told you snore when sleeping?
• Are you tired upon awakening from sleep or during the day?
• Do you fall asleep or are you drowsy in inappropriate situations such as in meetings, at church, or in social situations?
• Are you drowsy when driving?
• Do you have headaches in the morning?

If the response to any of these questions is “YES”, then the further questioning for a more comprehensive assessment of any potential sleep disorders may be necessary.

To further recognize a patient who may be at risk for OSA, the use of a common questionnaire known as the Epworth Sleepiness Scale (ESS) is utilized. The ESS identifies patients who are undergoing symptoms related to daytime sleepiness, which suggests the risk for OSA. This quick survey can be easily completed by the patient, and the scored results help the health care provider in considering the appropriate course of action that may be prudent, which most often, is a referral for a home sleep study or to the patient’s physician for further evaluation.

Interpretation of the ESS score is a common means of communication within the sleep medicine field regarding the risk for OSA increases. As the total score approaches 9, the risk for OSA increases. As the total score becomes greater than 9, then the risk factors are considered to be even more significant. However, an elevated score is not always conclusive for OSA and is also not indicative of its severity. The second portion of the ESS evaluates the patient’s behavior during sleep and more specifically some of the well-recognized characteristics associated with snoring that may suggest a raised risk for OSA such as waking up gasping for air or experiencing choking sensation during sleep. If snoring is the only recognized condition along with ESS total score being less than 9, then the risk for OSA may be less, but this is not always the case.

CLINICAL SCREENING FOR SRBD

Once a SRBD is suspected, it is advisable to perform a sleep disorder screening examination.  In most instances, a significant amount of clinical information regarding the patient’s dental and medical status and history has already been collected.  The screening evaluation will supplement the existing record with documentation that is designed to find relevant conditions that support the possible risk for SRBD, in particular for OSA.

SRBD history

The SRBD history is designed to obtain patients history-related findings that are specific to SRBD , such as the following patient symptoms or previously diagnosed conditions:

• Snoring
• Sleep apnea
• Low energy
• Bruxism
• Daytime sleepiness/tired
• Difficult to concentrate
• Previous or current use of positive airway pressure therapy (CPAP)
• Mood swings/irritable
• Feel depressed
• Headaches
• Previous surgery for SRBD

Review of Patient’s Medical History

The patient’s medical history may be revealing of an underlying sleep issue.  A number of preexisting medical conditions may suggest an increased risk for SRBD, particularly OSA, such as the following:

• Hypertension
• Cardiovascular disease
• Diabetes
• Headaches
• Respiratory conditions (especially asthma)
• Gastroesophageal acid reflux disease
• Hypothyroidism
• Allergy

Review of current medications

The patient’s current medications need to be reviewed.  There may be prescription medicines that are used for the management of a medical condition, yet the condition may be related to a sleep disorder.  In addition, many medications may have an impact on the patient’s sleep. Many times, a patient will list medication that treat Diabetes or High Blood Pressure. Yet, they the patient will not list the medical condition Diabetes or High Blood Pressure on the medical history form.

Medications and sleep

Almost all medications that are taken can impact sleep in some manner.

Not all patients have similar reaction to medications and patients may be taking medications for a particular health issue. These medications can also be an indicator that a sleep disorder is present but may have been overlooked or not considered.  Furthermore, there are many medications that are used to promote and improve sleep.

Medications by class associated with sleepiness

• Antihistamines
• Alcohol
• Anti-Parkinson agents
• Skeletal muscle relaxers
• Opiate agonists

Natural or alternative medications

• Ginseng
• Vitamin C
• John’s Wort
• Valerium
• Dehydroepiandrosterone (DHEA)
• Ephedra

Medications associated with insomnia

• Caffeine
• Nicotine
• Corticosteroids
• Amphetamines

Medications  for the treatment of insomnia 

• Sonata (zaleplon)
• Ambien (zolpidem)
• Lunesta (eszopiclone)
• Dalmane (flurazepam)
• Restoril (temazepam)
• ProSom (estazolam)
• Halcion (triazolam) – increases NREM stage 2 and interferes with slow-wave sleep
• Rozerem (ramelteon)-acts on melatonin receptors ( M1 and M2)

Medications that impact respiratory drive

May have an effect on OSA and chronic obstructive pulmonary disease

• Benzodiazepines
• Barbituates
• Narcotics
• Topamax

Antihypertensives’ effects on sleep

• Beta agonists (propranolol)
  Increased wakefulness
  Increase NREM stage1
  Decreased REM

• Ace inhibitors: Lotensin, Vasotec, Monopril, zestril, accupril, Altace
  Increased insomnia

• Diuretics (HCTZ)
  Drowsiness

Medications that increase slow-wave sleep

• Gabatril (tiagabine)
• Gabapentin (Neurontin)
• Pregabalin (Lyrica)
• Trazadone (Desyrel)
• Mirtazepine (Remeron)

When evaluating a patient who has a sleep disorder, medication use should be taken into consideration.  One research study demonstrated that the use of an antidepressant or antihypertensive

increases the risk for Obstructive Sleep Apnea.  The use of these two agents at the same time increases the risk for OSA significantly.

Temporomandibular disorders (TMD) assessment

 It is vital to be aware of a patient’s status relative to past or existing TMD, which may involve the temporomandibular joint (TMJ) and/or the masticatory muscles.  Although the TMD evaluation is often included as part of the initial new dental patient examination for every patient in a dental practice, a number of patients that present with a TMD condition may also have an underlying sleep disorder, and this may affect the overall management plan of the patient.

If a TMD condition is present, it is important to document its existence so that it can be further measured should an oral appliance be fabricated for OSA and/or snoring at some point in the future.

Temporomandibular joint

 In addition to documenting any findings concerning sounds and tenderness to palpation of the TMJs, there should be documentation regarding the patient’s mandibular range of motion.

 A screening assessment of the TMJs  should include  the following components:

• Previous treatment, including OA therapy
• Joint sounds (clicking,crepitus, popping)
• Range of motion (opening , protrusion, lateral excursions)
• Joint tenderness (capsule,retrodiscal)

Masticatory and cervical muscles

Palpation of the muscles of the head and neck should be performed to determine if there is any local tenderness or referred pain patterns.  A mindfulness of these masticatory and cervical muscles is essential on determining the source of the pain.  The muscles that were found to be tender should be recorded for future use.

Oral airway evaluation

 The following components should comprise the oral airway evaluation:

• Uvula
  Normal
  Enlarged/swollen
  Elongated
  Surgically removed

• Soft palate
  Normal
  Enlarged/swollen
  Slopes downward into the oropharynx

• Gag reflex
  Normal
  Diminished
  Absent
  Exaggerated

• Tonsils grade ( 0,I,II,III,IV)

Dentition and supporting structures

It is imperative that the patient’s current dental health status be recorded, which includes the teeth as well as the supporting structures.  The occlusion can change with the use of an Oral Appliance.

Components of documentation for the dental and supporting structures evaluation include the following:

• Classification of occlusion
• Deep bite
• Crossbite
• Periodontal status (no disease, gingivitis, recession, halitosis, abfraction, teeth mobility)
• Maxillary incisors (retroclined, normal)
• Wear facets on the teeth (mild, moderate, severe)
• Hard palate (narrow, high)
• Lip seal (strained/forced, no lip seal, lips dry/chapped)

Importance of lip seal

 Assessment of the patient’s ability to sustain a lip seal and identification of any indicators for mouth breathing are important components of the oral airway evaluation.  Lack of a lip seal and the resulting mouth breathing pattern or habit is also indicative of an individual who may have the following:

• difficulty breathing comfortably through the nose
• allergies
• nasal airway obstruction

Both mouth breathing and limited nose breathing can contribute to an increase in inspiratory pressure as well as to snoring and OSA because of airway compromise.

It is valuable to identify someone who may be a mouth breather.  When an individual is sitting comfortably in a relaxed position, the lips should be contentedly together without any appearance of being strained.  If the lips are not in contact and are apart, this is usually indicative of a chronic mouth breathing pattern, often referred to as an obligate mouth breather.  When this same individual attempts to close the lips, it will appear strained.  Also, the chin may appear tight or wrinkled, oftentimes a sign of increased mentalis muscle activity.

Tongue assessment

Evaluation of the tongue includes observation for scalloping, size, or coated surface.  The Mallampati score assess tongue position relative to the soft palate as well as visualization of the oropharynx as indicators of the risk for OSA.

As the degree of obstruction of the oropharyngeal airway and the soft palate increases, the risk for OSA also increases.  It has been demonstrated that as the score progresses from I to IV, the potential severity of OSA also worsens.  Also, for each 1-point increase in Mallampati score, the odds of having OSA were more than twice as likely, and the apnea-hypopnea index (AHI) may increase more than 5 events per hour.

Evaluation of the tongue should include the following components:

• Large
• Coated
• Scalloped
• Fisssured
• Tongue -tied (lingual frenum restricts movement)
• Mallampati score: o I o II o III o IV

Uvula assessment

 The appearance of the uvula may also indicate the risk for OSA and /or snoring.  The uvula may appear enlarged, swollen, elongated, and even bruised.  Negative intrapahryngeal pressure is related with a narrowed or obstructed airway. The abnormal appearance of the uvula can be a result of the mechanical trauma associated with the snoring and obstructive breathing events.

Soft palate assessment

 The soft palate is another necessary component of the evaluation by the dentist because of the clinical significance of the slope or length of the soft palate.  The more that the soft palate slopes down into the oropharyngeal space, the greater is the potential impact for airway obstruction. Plus, the more the soft palate slopes downward, the higher the Mallampati score.

As with the uvula, the soft palate may also appear swollen from the mechanical trauma associated with snoring and /or OSA.

Tonsils assessment

The enlargement of the tonsils may contribute to airway obstruction as well as an increased tendency for mouth breathing.  This expansion can also compromise the airway and contribute to snoring and OSA.  This is particularly true in children and adolescents.  In adults, this can also be the case but to a lesser degree.  The standard grading system for the tonsils rate them on a scale from 0 to IV, with 0 indicating that the tonsils are absent and grade IV indicates they are grossly enlarged.

Typically, as one goes through puberty, the size of the tonsils will decrease to a grade I or 0.  Sometimes this will not occur, and this is when they may impact the airway.  Therefore, the evaluation of the tonsils should be a routine part of the oral airway evaluation.

Nasal airway evaluation

 Nose breathing is the preferred mode of respiration despite the fact that many patients are habitual mouth breathers.  Chronic mouth breathing is often associated with nasal airway obstruction.

The nasal airway is important because it warms and humidifies the air and filters the air.

MANAGEMENT PLAN

 Once all the data from the various components of the evaluations have been completed by the dentist, a plan needs to be presented to the patient.  The overall outcome most often will involve either the patient going on for further testing such as a sleep study or getting an OA.  Regardless, various options should be explored as part of the consultation:

• Schedule
  • Consultation with the dentist
  • Schedule a more detailed evaluation
• Refer patient for a sleep study or to the physician
• Patient had a sleep study-obtain copy for review
• Patient tried positive airway pressure therapy and/or had surgical intervention- consider OA therapy
• Schedule for OA therapy
• Need Cone beam imaging
• Recommend
  • Commercial nasal dilator(e.g., Breathe Rite© strips)
  • Commercial sinus rinse ( e.g., Neil Med© Sinus rinses)

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