Most people have visited a dental office and are familiar with the typical services offered. In our office many are surprised when presented with a Sleep Health Questionnaire (SHQ) as part of their new patient paperwork. Questions like "Have you ever been told you snore?", "Have you ever been told you stop breathing while asleep?", and "Are you currently using a CPAP machine?" are now becoming more commonplace at the dentist.

Many people suffer from snoring activity during sleep. While half of these people are "simple snorer's" the other half may have a serious sleep disorder called Obstructive Sleep Apnea (OSA).

Treating snoring, while not medically necessary, can have dramatic effect on one's quality of life. Many of our patients report not being able to spend the night in the same room as their spouse. It's a wonderful feeling to have a patient return and say "my spouse loves this office, last night we slept in the same room and she didn't hear me once."

On the other end of the spectrum is obstructive sleep apnea which is a very common and potentially life-threatening medical disorder that prevents airflow during sleep. As much as 20% of the adult population in the United States has sleep apnea, and many are not receiving treatment.

Sleep apnea occurs when tissue in the back of the throat collapses and blocks the airway, reducing the amount of oxygen delivered to all of your organs including your heart and brain. People with sleep apnea may snore loudly and stop breathing for short periods of time. When the blood-oxygen level drops low enough, the body momentarily wakes up.

It can happen so fast that you may not be aware you woke up. This can happen hundreds of times a night, and you may wake up in the morning feeling unrefreshed.

For years the treatment of choice has been the CPAP machine, which uses mild air pressure to keep the airways open. This has been effective as long as patient compliance can be achieved. Patient compliance is however a serious challenge. It's been estimated that 30-50% of patients that have been recommended a CPAP actually wear it. Common complaints about the CPAP include that it is uncomfortable, loud, embarrassing, cause's marks on the face, and dries out patient sinuses.

More and more patients are looking for alternatives to the CPAP machine. Oral appliances have become a desirable alternative due to its many advantages. Their acceptance rate is in the 70-90% range and they are becoming the treatment of choice for patients with mild and moderate sleep apnea. The American Academy of Sleep Medicine recommends oral appliance therapy for patients with mild to moderate OSA and for those with more severe OSA who cannot tolerate CPAP and refuse surgery.

A custom dental appliance helps to reposition the jaw and tongue to improve airflow while reducing or eliminating the patients snoring. The primary action is to increase and stabilize the oropharyngeal and/or hypopharyngeal airway space. There are currently eleven FDA approved devices used to treat OSA, known as Mandibular Advancement Devices (MAD). All MADs are successful in improving Apnea Hypopnea Index (AHI) and Respiratory Distubrance Index (RDI), and comparison with inactive appliances suggests that mandibular advancement is crucial in terms of establishing efficacy. There is no 'one fits all' MAD--the choice of which MAD is 'best' in improving polysomnographic indices depends on a variety of factors ranging from severity of OSA, materials used and method of fabrication, and design features to individually determined sagittal/vertical protrusion. For these reasons a dentist is the ideal health professional to ensure that these devices are properly fitting and cared for.

Once an appliance is delivered it is important that the dentist partner with the patients physician to provide oversight on the efficacy of the appliance. Typically our office follows up at three week intervals with the patient to make sure the device is comfortable and effective. Patients are given forms like the Epworth Sleepiness Scale and the Observation of Sleep Scale, for their bed partner, to evaluate if the device is improving their quality of sleep. This aspect is very important as it allows us to determine if the patient is ready for an efficacy sleep study. Proper follow up with the patient is important to ensure the device is both comfortable and effective, while encouraging the patient to remain compliant.

So how do we get started? Before beginning OSA therapy it is essential for the patient to have completed a sleep study and have it analyzed by a sleep physician. This can be done at a sleep center or with an In-Home Testing system. Many times our patients have already completed a sleep study, which we are happy to use. Occasionally this study is a number of years old and may need to be updated. For patient convenience our office has partnered with a board certified sleep physician to provide In-Home testing services. Once a diagnosis and treatment recommendations have been made by the sleep physician our office consults with the patient to discuss all possible treatment options and see if an oral appliance is right for them.

With everything we know about sleep apnea it's no wonder why patients are looking for treatment. In addition to snoring and excessive daytime sleepiness, sleep apnea can cause memory loss, morning headaches, irritability, depression, decreased sex drive and impaired concentration. Sleep apnea patients have a much higher risk of stroke and heart conditions, such as heart attack, congestive heart failure and hypertension. Sleep apnea patients are also more likely to be involved in an accident at the workplace or while driving.

It's important that we give patients all the treatment options available. Surgery, CPAP, and oral appliances can all be used to treat OSA. Oral appliances are appealing because they are less invasive than surgery and have a higher compliance than CPAP. It's important to partner with a dentist that is familiar with the process from medical diagnosis, evaluation of dentition and mastication, delivery of appliances, proper follow up, and medical insurance billing. I encourage medical doctors to reach out to dentists who regularly treat these conditions so patients can be educated about all their options.

Dr. Ivan Montijo earned his Doctorate in Dental Medicine from the University of Florida and practices at Lake Nona Dental Group. He is trained in all aspects of dentistry and stays on the cutting edge of dental technology. Dr. Montijo is a Fellow of the Academy of General Dentistry which is awarded to dentists with a commitment to continuing education beyond the post-graduate level and is achieved by less than 3% of practicing dentists nationwide.
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