Screening for Sleep Apnea – Helpful or Not?

nodding offThere’s a new report on sleep apnea in JAMA, and it has us a little…well, restless. We think it may send the wrong message and prevent people from getting the help they need to get a good night’s sleep.

The report sought to find if screening for obstructive sleep disorder (OSD) or obstructive sleep apnea (OSA) is effective. All in all, it said, there’s not enough evidence to suggest that it is.

“There is uncertainty about the accuracy or clinical utility of all potential screening tools,” wrote the group led by Daniel Jonas, MD, MPH, an associate professor of medicine at the University of North Carolina at Chapel Hill.

It’s estimated that over 18 million people have some form of obstructed sleep disorder, many of whom go undiagnosed. OSA itself has been linked to a number of serious health conditions, including heart disease, type 2 diabetes, and stroke. Hence, the recommendation that dentists and doctors screen their patients.

The current study reviewed 110 studies with more than 46,000 patients. The goal was threefold:

  1. To evaluate primary care-relevant evidence on screening adults for OSA.
  2. To evaluate test accuracy and treatment.
  3. To inform the U.S. Preventive Services Task Force.

While they found that multiple treatments for OSA were able to reduce AHI, Epworth Sleepiness Scale scores and blood pressure, they couldn’t establish if these reduced mortality or improved other health outcomes. But they did find evidence of a modest improvement in sleep-related quality of life.

Results based on insufficient evidence concern Susan Redline, MD, MPH, who noted in an editorial in the same issue of JAMA,

While the USPSTF found insufficient evidence on screening for OSA in asymptomatic adults, high priority should be given to additional studies that generate rigorous evidence that will serve to improve the recognition and treatment of OSA in the population and reduce its attendant morbidity. However, the current recommendations, if misinterpreted, could negatively influence public health if they are used to discourage direct questioning or deployment of short screening questionnaires for identifying patients at high risk for OSA. Encouraging patient and clinician discussion of relevant symptoms and signs of OSA is one way to help address early recognition.

We agree.

As we noted just a couple weeks ago, we dentists we are in a unique role to not only screen and treat patients with OSD, but we see the positive results in our patients. And we believe that even the “modest” improvements noted by the study are beneficial to overall health and well-being.

Image by andy wagstaffe

Help for Sleep Apnea from Your Dentist? Yes!

sleep apnea diagramMost people with obstructive sleep apnea (OSA) probably don’t know it. In fact, it’s often a sleeping partner who first notices the common signs. After all, the snoring’s not keeping you awake.

But there’s another person who can tell you if you may have OSA: your dentist.

According to a study published last year in the Saudi Medical Journal, dentists have a unique advantage to hone in on the signs of sleep apnea. Because they see into patients mouths more often than physicians do, they have more opportunities to notice indications of airway obstruction – specifically, enlarged tonsils and scalloping along the sides of the tongue.

Other research has suggested even more dental signs of possible OSA, including worn teeth, morning headaches, gum problems, and TMJ pain.

Of the more than 18 million adults in the US affected by sleep apnea, those who are obese are 10 times more likely to report symptoms than their slender counterparts. According to the National Sleep Foundation, many of those 18 million go undiagnosed. Without diagnosis and treatment, the sleep apnea issues compound. OSA has been linked to heart disease, diabetes, depression, memory loss, and more.

Once sleep apnea is diagnosed through a sleep test, dentists can play a role in effective treatment, as well.

Whether you have a history of OSA and use a CPAP device or are searching for help with a recent diagnosis, you may be interested to learn about how less invasive oral appliance therapy can treat mild to moderate cases of sleep apnea. Appliance therapy tends to be more comfortable than CPAP, while also effective in keeping the airway open.

In fact, oral appliance therapy is now the recommended treatment of the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine for adults who are CPAP intolerant or prefer an alternative.

“This evidence-based guideline reinforces the fact that effective treatment options are available for obstructive sleep apnea, a chronic disease that afflicts at least 25 million adults in the U.S.,” said AASM President Dr. Nathaniel Watson. “Although CPAP therapy is still the first-line option for treating OSA, oral appliance therapy is an effective alternative that is preferred by some patients. Sleep medicine physicians and dentists can promote high quality, patient-centered care by working together to identify the optimal treatment for each patient who has sleep apnea.”

Most appliances work by supporting the lower jaw in a slightly forward position. This forward position keeps the tongue from dropping back toward the throat. Over time, this helps tone the tissues that line the throat. Wearing an appliance can sometimes double and even triple the size of the airway opening.

These appliances are not “one-size-fits-all” devices. There are dozens of options available. Only a dentist well-versed in breathing disorders such as OSA can help determine the best choice for your unique situation and help get you on the path to better sleep – and better overall health for the long haul.

Sleep Apnea Solutions

As we mentioned before, more than 18 million Americans are believed to suffer from obstructive sleep apnea (OSA), a disorder in which breathing is interrupted during sleep.

OSA can lead to insomnia and irregular sleep patterns, teeth grinding (bruxism), chronic allergies, earaches, acid reflux and hypertension. And it’s more than just a nuisance. It can be life-threatening. After all, when the upper airway is blocked, oxygen can’t get to the brain! This, in turn, affects other parts of your body – both organs and muscles (and your heart is one big muscle). It has been linked with conditions such as heart attack and stroke.

Clearly, doing nothing about it is NOT a great option.

cpapOne of the most common treatments for it is the use of a CPAP machine, where CPAP stands for “continuous positive airway pressure.” It consists of three parts: a mask to cover your mouth and nose, a tube to connect the mask to the machine, and a machine which creates air to blow into the patient’s airway.

Suffice it to say, CPAP has its drawbacks, which contribute to notoriously low compliance rates with the therapy. Some patients complain that the machine is cumbersome or makes them feel claustrophobic. Some complain of stuffy noses, dry mouth and skin irritation.

And a new case report, published in the journal Bipolar Disorders, suggests that it may trigger manic symptoms in those diagnosed with that condition. The extreme euphoria associated with bipolar disorders – the total opposite of the extreme depression on the other end of the pole – brings behavioral changes, such as talking too fast and erratically, shopping excessively and uncontrollably and acting impulsively. It’s not hard to see how this could easily mess with one’s ability to perform basic day-to-day tasks.

While more research on this potential side effect of CPAP, the authors of the case report caution that

Clinicians need to monitor patients with bipolar disorder closely for worsening of manic symptoms when they are started on CPAP for underlying OSA.

Of course, there are alternatives for dealing with OSA. In fact, new guidelines from the American College of Physicians indicate that weight loss should be the first treatment where obstructive sleep apnea is suspected.

“Not everyone with sleep apnea is overweight, but most patients are,” [Dr. Molly] Cooke says. Losing weight gets rid of fat that blocks the windpipe. It would “not only fix your sleep trouble, it would help your cholesterol, it would help your knees, your clothes would fit better and you would be a happier person,” she says.

Patients who still have symptoms at that point might need to go to a sleep clinic and do an overnight test for apnea.

For people who are diagnosed by a sleep clinic, the No. 2 treatment of choice is CPAP, or continuous positive airway pressure.

At least when it comes to conventional medicine. Many consider oral appliance therapy (OAT) to be the frontline treatment at least for mild to moderate OSA – or for those who cannot use CPAP for whatever reason. (At least one study has shown that it may be “effective in controlling…more severe forms of OSA.) These custom-fit devices “reposition the lower jaw, tongue, soft palate, and uvula,” and strengthen the tongue, keeping it from falling back when relaxed, obstructing the airway.

Another alternative is myofunctional therapy, which involves exercises to retrain the muscles of the face and oral cavity, restoring them to proper function. Research continues to support the usefulness in dealing with sleep apnea and a host of other issues. Both the International Association of Orofacial Myology and the Academy of Orofacial Myofunctional Therapy provide online directories of therapists worldwide.

Dietary changes can also prove helpful.

For more on how the dentists here at Pride Dental can help, visit our sleep apnea page – or contact us today.

Image by Brandon, via Flickr