NMDA Journal Summer 2019

nmdental.org 19 Radiographic Signs: • Enlarged turbinates (visualized on most panos, AP ceph, and CBCT) • Enlarged adenoids (visualized on most panos, Lateral ceph, and CBCT) • Deviated septum (visualized on most panos, AP ceph, and CBCT) • Below average lower airway dimension (seen on Lateral ceph and CBCT) Behavioral Signs: • Chronic fatigue and daytime sleepiness • Chronic“allergy-like”symptoms • Attention problems in school (ADHD) • Bed-wetting (throws off ADH release/rhythm) • Nocturnal clenching/grinding • High blood pressure When these signs are seen in conjunction with dental/skeletal maloc- clusion, it is our job to not only treat the malocclusion, but to also refer to the appropriate medical practitioners (ENT, sleep physician, speech language pathologist, myofunctional therapist, dietitian, etc.) to address the underlying airway issues. If the airway is the underlying cause of the malocclusion and is not addressed, the patient has a high chance of relapsing orthodontically and does not benefit functionally with breathing/airway enhancement. Start Asking Questions First and foremost, we should be asking some simple screening questions to our patients because we know that the two biggest symptoms of sleep apnea are snoring and daytime sleepiness, with a strong third being hypertension later in life. There are many screening questionnaires that providers can use as quick yet effec- tive tools in determining the likelihood of sleep apnea in patients. The following are some quick, easy questionnaires that you can ask your patients in the chair while they are in for their routine ap- pointments: Epworth Sleepiness Scale, STOP BANG, and NoSAS. A simple Google search will provide you the questions to ask, and this doesn’t need to be some big production that you add to your patient’s appointment. If you ask a few quick questions and look for some of the signs then I guarantee you will start seeing the prevalence of sleep apnea. Even if you don’t use these official questionnaires, simply ask them, “Have you been told you snore?” I have been shocked and humbled by the amount of detail my patients have gone into after opening up with this one question and the fact they we had completely overlooked it until now. Some may shrug it off at first only to fol- low it up with details that they either already were diagnosed with some form of apnea or their PCP has been bugging them for years to do a sleep study. The patients with OSA are sitting in your chair waiting to be given a solution for their problems, whether they know it or not. How is OSA Diagnosed All forms of sleep apnea must be diagnosed by a sleep physician after review of a sleep study. A polysomnogram (PSG) gives the most data for a sleep study, but there are also home sleep tests (HST) that patients can wear a unit on their head and sleep in their own home. These are still accepted diagnostically. Dentists can screen with Stop- BANG and Epworth Sleepiness Scale and identify other signs and risk factors. Then refer for a sleep study (PSG or HST) but are advised to treat cases only after a sleep study has confirmed diagnosis and has been signed by a sleep physician. One other useful tool is acoustic pharyngiometry and rhinometry. This is the use of a device that uses sonar (sound waves) to measure a patient’s cross-sectional area of their airway. This does not always predict nor does it diagnose sleep apnea in patients; it does however alert the patient and provider to possible problems with their airway. It can also be used in treatment to find an “optimal” treatment posi- tion if the patient is going to wear a nighttime appliance. There are certain criteria that need to be met to be officially diagnosed with sleep apnea. The most important of those being that the patient needs to undergo a sleep study within the last five years, and that sleep study needs to be read and diagnosed by a certified Sleep MD. Within that sleep study the primary values that are pertinent for medi- cal diagnosis are an apnea hypopnea index (AHI). What this shows is the number of times per hour that a patient has either a complete stop of breathing (apnea) for 10 seconds or more or a decrease in airflow by 30% (hypopnea) with a decrease in oxygen saturation of at least 4%. An AHI >5 is necessary for an official diagnosis (Mild=5- 15, Moderate=16-30, Severe=30+). These numbers show the average number of times per hour that a patient is having an apnea or hypop- nea during an entire night of sleep. So an AHI of 10 would mean that they are ceasing to breath or having inhibited airflow a total of 70 times if they slept for 7 hours. These results will also show the details of oxygen desaturation as well as if the apneas are related to the pa- tient’s position they are sleeping in because sometimes apneas only happen when they are supine. One big distinction that these will show is if the sleep apnea is due to airway obstruction or centrally mediated. If a patient is diagnosed with central apnea, they must be referred to a sleep physician to treat with positive air pressure device (PAP) as that is the only effective treatment for central apnea. Treatment We will only be concerned with obstructive sleep apnea from here on out because it is the only one that we are capable of giving any treatment or therapy for. There are three general ways or categories of OSA treatment. PAP therapy, surgically/orthodontically, and man- dibular advancement devices (MAD). PAP therapy is the standard of care for sleep physicians if surgery is not pursued. Sleep physicians and dentists differ in their studies on compliance with PAP therapies. Research shows PAP therapy is significantly better at reducing the AHI during sleep than an oral appliance. PAP therapy is immediately effective, and many types of masks are available. All reasonable at- tempts to havea patient wear a PAP mask should be attempted be- fore MAD unless otherwise directed in the sleep study. PAP devices have been showed to work extremely well no matter the severity of sleep apnea; however, they only work if and when the patient is continues on page 20 