How to Treat Sleep Apnea: Expanding Clinical Dentistry

Sleep apnea, particularly obstructive sleep apnea (OSA), is a growing concern in healthcare due to its significant impact on overall health. As healthcare providers, dentists have an expanding role in recognizing, managing, and treating sleep apnea through interdisciplinary collaboration. Understanding OSA, its effects on health, and the potential for dental interventions is crucial for improving patient outcomes.

What is Obstructive Sleep Apnea

OSA is characterized by the repetitive collapse of the upper airway during sleep, leading to reduced airflow, decreased oxygen levels, and frequent arousals from sleep. The condition is associated with symptoms of excessive daytime sleepiness, impaired cognitive function, and even increased cardiovascular risk and mortality. With these consequences in mind, dental professionals are uniquely positioned to play a role in the early detection and treatment of OSA, especially in collaboration with sleep specialists.

The Importance of Recognizing and Treating Sleep Apnea

Sleep apnea’s widespread impact on quality of life and health has prompted growing recognition of its significance in clinical practice. As healthcare professionals, dental clinicians should understand the oral manifestations and treatment options for sleep apnea. Early identification by dental clinicians can enable timely intervention and meaningfully improve patient outcomes.

There are an estimated 425 million people worldwide suffering from moderate to severe OSA. In the United States alone, about 25 million adults are affected by OSA, many of whom remain undiagnosed. Dental clinicians, who routinely assess patients’ oral anatomy, can contribute to better screening and treatment efforts.

What Is the Scope of Practice for Dentists Regarding Sleep Apnea?

Dentists have an important but specific scope of practice when it comes to managing sleep apnea, particularly OSA. While they cannot diagnose OSA on their own, dentists can play a vital role in screening, educating, and treating patients as part of a broader care team. The collaboration between dentists and sleep specialists is crucial for ensuring patients receive appropriate and timely treatment.

What Dentists Can Do:

• Screening for Sleep Apnea: Dentists are often the first healthcare professionals to identify potential signs of OSA, such as bruxism, a scalloped tongue, or a narrow airway. By looking for the signs and symptoms of sleep apnea, dentists can refer patients for a definitive diagnosis from a sleep physician.

• Providing Oral Appliance Therapy (OAT): After a diagnosis is made by a physician, dentists can treat patients with mild to moderate OSA by providing custom-fitted oral appliances, such as mandibular advancement devices (MADs). These devices help to keep the airway open during sleep by repositioning the jaw.

• Educating Patients: Dentists can educate patients on the risks associated with untreated sleep apnea and the benefits of oral appliance therapy. They can also inform patients about other treatment options, including continuous positive airway pressure (CPAP) therapy or surgical interventions.

• Recommend Lifestyle Modifications: If applicable, dentists may also recommend lifestyle changes for patients that might benefit

  • Losing weight

  • Quitting smoking

  • Avoiding alcohol and other sedatives like CBD before bed

• Collaborating with Sleep Physicians: Dentists work closely with sleep specialists, especially after a sleep study has confirmed a diagnosis of OSA. This partnership ensures that oral appliance therapy is appropriately fitted and monitored for effectiveness.

What Dentists Can’t Do:

• Diagnose Sleep Apnea: While dentists can screen for potential signs, they do not have the authority to diagnose OSA. A definitive diagnosis must be made by a licensed sleep physician, typically after an overnight sleep study or home sleep apnea test.

• Use Sleep Studies for Diagnosis: Dentists cannot conduct or interpret sleep studies. These must be handled by sleep specialists who have the appropriate training and equipment.

• Solely Manage Complex OSA: For patients with severe OSA or complex medical histories, dentists must collaborate with sleep specialists to ensure that more intensive treatments, such as CPAP or surgery are considered.

For dentists who want to get started in dental sleep medicine, it’s important to gain the necessary training to feel confident in your clinical practice. Awaken2Sleep offers a comprehensive guide on the fundamentals of dental sleep medicine, outlining the steps dentists can take to integrate sleep apnea care into their practices. From understanding the science of sleep apnea to obtaining the right equipment and partnerships with sleep physicians, resources like these are essential for dentists looking to expand their role in treating OSA.

How to Recognize Obstructive Sleep Apnea

Many patients with OSA may first present to a dental clinic with symptoms like bruxism, dry mouth, or jaw pain. In these circumstances, dental professionals can start screening for OSA by asking patients about sleep disturbances, snoring, and daytime fatigue. If the patient has had any of these symptoms, next steps include reviewing patient medical history, including medications.

Medical history that dental clinicians should be aware of for patients with suspected OSA include:

Medical Conditions Relevant to Obstructive Sleep Apnea (OSA)

Obesity

• Increased risk due to airway obstruction from excess weight distribution.

Cardiovascular Disease (Hypertension, Heart Failure)

• OSA is associated with increased cardiovascular risks.

Type 2 Diabetes

• Relevance: Higher prevalence of OSA among patients with diabetes, linked to insulin resistance and metabolic syndrome.

Snoring and Daytime Sleepiness

• Classic symptoms of OSA, indicating disrupted sleep and breathing during sleep.

Bruxism (Teeth Grinding)

• Often linked to sleep disorders, especially OSA.

Large Neck Circumference (>17 inches in men, >16 inches in women)

• Associated with a higher risk of airway obstruction during sleep.

Chronic Nasal Congestion

• Can contribute to breathing difficulties during sleep.

Use of Sedatives, Alcohol, or Recreational Drugs

• These substances can worsen OSA by relaxing the muscles of the airway.

Family History of Sleep Apnea

• Genetic predisposition to sleep-disordered breathing.

GERD (Gastroesophageal Reflux Disease)

• Correlated with sleep apnea and reflux, which can exacerbate breathing difficulties during sleep.

History of Stroke or TIA (Transient Ischemic Attack)

• Sleep apnea can increase the risk of stroke, and previous strokes may worsen OSA symptoms.

Dental clinicians should also be aware of the most common classes of medications that contribute to OSA including:

Medication Classes and Their Effect on OSA

Alcohol

• Acts as a central nervous system depressant.

• Can worsen sleep apnea and lead to weight gain, exacerbating OSA.

Sedatives (e.g., Benzodiazepines)

• Depress airway muscle activity.

• Potentially worsen apnea events.

• Increase daytime sleepiness.

Benzodiazepine Receptor Agonists

• Similar effects to benzodiazepines.

• Can reduce respiratory drive.

• Increase sleep-disordered breathing.

Barbiturates and Antiepileptic Medications

• Suppress the central nervous system.

• Worsen sleep quality.

• Potentially increase OSA events.

Sedating Antidepressants (e.g., Tricyclics)

• Can worsen OSA symptoms by increasing airway collapse.

• Contribute to weight gain.

Antihistamines

• Sedative effects can exacerbate sleep apnea.

• Relax airway muscles, worsening OSA.

Opiates

• Suppress respiratory function.

• Worsen OSA severity.

Mirtazapine (Select Antidepressant)

• May cause weight gain.

• Can lead to restless legs syndrome.

• Further aggravates sleep disturbances.

Cannabis

• Not recommended for treating OSA.

• Lack of evidence and potential adverse effects on respiratory function.

It is essential to review each of your patients’ medications when screening for OSA, as they may be a primary contributing factor to the condition. To assist with this, DentalRx provides a Patient Med History screening tool that notes contributory medications when managing OSA.

What Treatments Can Dentists Provide for Sleep Apnea?

The integration of oral appliance therapy (OAT) into dental practice offers a non-invasive alternative for treating mild to moderate OSA, providing relief to patients who may not tolerate continuous positive airway pressure (CPAP) therapy. By working collaboratively with sleep medicine specialists, dental professionals can optimize treatment outcomes and enhance patient care.

Literature-Based Guidelines

OSA has well-documented and evidence-based guidelines from sources like the American Academy of Sleep Medicine (AASM) which emphasize the interdisciplinary approach to treatment. Dental clinicians can manage OSA through oral appliances called mandibular advancement devices (MADs) which reposition the mandible to prevent airway obstruction during sleep. Research highlights the effectiveness of these devices in reducing apnea events, improving oxygen saturation, and enhancing patients’ overall quality of life​.

For patients unable to tolerate CPAP or seeking alternative treatments, oral appliance therapy like MADs are recommended first-line therapy for mild to moderate OSA.

Treatment

Mild to Moderate OSA

• Indication: Oral appliance therapy is indicated for patients with mild to moderate OSA who cannot tolerate or prefer not to use CPAP therapy. It is also suitable for patients with severe OSA who are CPAP-intolerant or have failed CPAP therapy.

• Recommendation: The use of mandibular advancement devices (MADs) is recommended as a first-line treatment for mild to moderate OSA. These custom-fitted devices work by repositioning the lower jaw to keep the airway open during sleep. For patients with severe OSA who cannot tolerate CPAP, oral appliances may serve as an alternative therapy.

• Alternatives: In addition to OAT, CPAP remains the gold standard for severe cases of OSA. Surgical interventions, such as uvulopalatopharyngoplasty or hypoglossal nerve stimulation, may also be considered for patients who do not respond to conservative treatments.

   

Snoring and Mild OSA

• Indication: Oral appliances are also recommended for the treatment of primary snoring with or without sleep apnea. They can be used in patients who are looking to reduce snoring and improve sleep quality without the need for more invasive treatments.

• Recommendation: For patients with primary snoring or mild OSA, an oral appliance that advances the mandible may be beneficial. These devices are especially helpful in patients who snore due to anatomical factors such as a narrow airway or large tongue.

• Alternatives: Positional therapy, weight loss, and lifestyle modifications are also effective for reducing snoring and mild sleep apnea symptoms. These should be considered alongside oral appliances.

The Role of Dentists in Sleep Apnea Treatment

Dentists play a vital role in the management of sleep apnea. Having resources like the ones from Dentist2Sleep or this guideline can ensure you are taking the right steps towards providing the highest quality care for your patients.

If you ever need to reference this guideline, it is always available for free on our app.

In addition to platforms like DentalRx and Dentist2Sleep, companies such as Dentulu are embracing this new scope of practice by integrating technology with dental sleep medicine. Dentulu has recognized the patient need for this enhanced scope of practice and is leading the way with teledentistry consultations and at-home sleep tests that help patients get diagnosed with OSA. Dentulu also offers patients customized Sleep Apnea Mouth Guards if they are indicated.

By offering tools for screening and management, Dentulu empowers dental clinicians to take a more proactive role in treating OSA. At DentalRx we hope to see more of the dental ecosystem adopt this holistic approach, where the collaboration between sleep specialists and dentists is commonplace, creating better outcomes for patients suffering from sleep disorders.

Conclusion

Sleep apnea represents a significant health burden, but dental professionals are uniquely positioned to play a role in its management. Through oral appliance therapy and interdisciplinary collaboration, dentists can help identify and treat patients with OSA, improving their quality of life and overall health.

References

• Benjafield, A. V., Ayas, N. T., Eastwood, P. R., Heinzer, R., Ip, M. S., Morrell, M. J., … & Malhotra, A. (2019). Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. The Lancet Respiratory Medicine, 7(8), 687-698. https://doi.org/10.1016/S2213-2600(19)30198-5

• British Columbia College of Oral Health Professionals. (2022). Obstructive Sleep Apnea: The role of dentists in the treatment of snoring and obstructive sleep apnea with oral appliances.

• Source: Dentulu. (n.d.). Sleep Apnea Mouth Guards. Retrieved from https://www.dentulu.com/sleep-apnea-mouth-guards.html 

• Source: Awaken2Sleep. (n.d.). The Fundamentals of Dental Sleep Medicine. Retrieved from https://awaken2sleep.com/the-fundamentals-of-dental-sleep-medicine/