Snoring and Obstructive Sleep Apnea from a Dental Perspective

By Rob W. Veis, DDS

Proper diagnosis and treatment of sleep-related disorders are best handled via a team approach. This team may include a general dentist treating in conjunction with other sleep specialists. However, to provide care, dentists must have a basic understanding of sleep disorders. This paper provides a dental overview of sleep-related breathing disorders, including key definitions, an outline of a diagnostic protocol, a discussion of the factors involved in decision-making, and a summary of the wide variety of treatment modalities.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

Perhaps one in every 10 adults snores. Although snoring has no serious medical consequences for most people, for an estimated one in 100 snorers, habitual snoring is the first indication of a potentially life-threatening sleep disorder called obstructive sleep apnea.¹

Most physicians have not been trained to deal with sleep-related disorders. It has been estimated that, on the average, only two hours are spent during the four years of medical school teaching medical students about sleep.² This has created a significant deficit in our current medical system. Dentists can help correct this problem by participating in the recognition and treatment of sleep disorders.

By adding a few questions relating to sleep to a standard dental screening form, a dentist can recognize a potential sleep disorder. This alone could help guide millions of Americans who suffer from a sleep disorder into a systematic treatment pathway. However, to provide care, dentists must have a basic understanding of the complex process of sleep and sleep disorders.¹

Sleep Nomenclature

Sleep Architecture

In a normal rest period, the average person will repeatedly cycle through different stages of sleep to create what is called a "normal sleep architecture." The two main divisions of a normal cycle are non-rapid eye movement (non-REM) and rapid eye movement (REM).³

Non-REM consists of four stages. The first stage is the transitional stage. This is the time when one is falling asleep, and it usually represents only 5 percent of sleep time. The second stage is the light sleep stage. This stage accounts for 50 percent of normal sleep time. The third and fourth stage of non-REM are the delta and slow-wave stages. These stages represent about 20 percent of sleep time and are the stages in which one experiences a deep and relaxing state of rest.^3,4

After the non-REM cycle is complete, one usually enters into REM sleep. Restful sleep continues during this cycle. It is also the period in which one dreams. This stage accounts for the final 25 percent of a normal sleep cycle.^3,4

To experience a restful night sleep, one must spend sufficient time in deep sleep. A person suffering from sleep apnea cannot do this because they are constantly awakened throughout the night.⁴

Sleep Apnea

Stedman's Medical Dictionary defines apnea as the absence of breathing or the want of breath. When there is a cessation of airflow at the mouth and nose for more than 10 seconds, an apneic episode has occurred. During this time, the individual's oxygen level will drop. If a person experiences 30 or more apneic episodes during a seven-hour sleep period, that person is believed to be suffering from sleep apnea syndrome.^3,5 These episodes can last from 10 to 120 seconds. These apnea events terminate with a partial wakening or an arousal. It is important to understand that these arousals are necessary for the person to begin breathing again. Apnea severity is usually categorized by the frequency of apnea events that occur per hour. This number is called the apnea index.³ The categories are as follows:

* Mild -- Five to 20 episodes per hour;

* Moderate -- 20 to 40 episodes per hour; and

* Severe -- 40 or more episodes per hour.

It is not unusual for a patient with severe apnea to have as many as 300 apneic episodes per night.

Sometimes there is a decrease in airflow but not a complete blockage. When this happens for 10 seconds or more and there is a decrease in oxygen level of at least 2 percent, an event called a hypopnea has occurred. Hypopneas also lead to an arousal from sleep.⁶

There are three basic classifications of sleep apnea: central, obstructive, and mixed.

* Central apnea. Airflow stops because inspiration efforts temporarily cease. Although the airway remains open, the chest wall muscles make no effort to create airflow. The etiology frequently is encephalitis, brainstem neoplasm, brainstem infarction, poliomyelitis, spinal cord injury, and cervical cordotomy.^3,7 This is a fairly uncommon form of apnea.

* Obstructive sleep apnea. This is the cessation of airflow due to a total airway collapse despite a persistent effort to breathe. An obstruction in the upper airway can occur in three areas.⁸ They are the nasopharyngeal, oropharyngeal, and hypopharyngeal regions. The nasopharynx is the part of the pharynx that lies above the level of the soft palate. The oropharynx is the division of the pharynx that lies between the soft palate and the upper edge of the epiglottis. The hypopharynx is the division of the pharynx that lies below the upper edge of the epiglottis and opens into the larynx and esophagus.

Regardless of the level, an obstruction causes breathing to become labored and noisy.¹ As pressure to breathe builds, muscles of the diaphragm and chest work harder. The effort is akin to sipping a drink through a floppy straw -- the greater the effort, the more the walls collapse. Collapse of the airway walls eventually blocks breathing entirely. When breathing stops, a listener hears the snoring broken by a pause until the sleeper gasps for air and awakens, but so briefly and incompletely that he or she usually does not remember doing so in the morning.^4,7

* Mixed apnea. This term is used when both central and obstructive episodes are observed during a sleep study. It is usually recorded as a central episode being immediately followed by an obstructive one.³ When this is seen, the obstructive component is treated first. This usually eliminates the problem; but when it does not, re-evaluating the patient for a central component will have to be done.

Snoring

Many people think that snoring and apnea are the same thing. This is not true. Snoring, which is caused by vibration of the tissues due to air turbulence as the airway narrows, may be a sign that a patient is suffering from apnea. But not all snorers are apneics.

Snoring can be categorized by its severity. On one end of the spectrum is the benign snorer who snores but experiences no physical problems. On the other end lies the snorer who suffers from apnea, and in the middle is the snorer who suffers from upper airway resistance syndrome. In these people, though they may not actually experience apneic episodes, their snoring is so loud and their breathing so labored, that it still wakes them up numerous times throughout the night. This leaves them unrefreshed and tired throughout the day.⁶

Reasons to Treat and Who Should Be on the Team

Patients who suffer from sleep apnea typically suffer from a fragmented sleep pattern, experience excessive daytime sleepiness, and exhibit many other medical conditions. Some of the more common conditions associated with sleep apnea are hypertension; stroke; angina pectoris;⁹ initiation of a gastroesophageal reflex; frequent nocturnal voiding; hypoxemia; hypercapnia (high blood level of CO₂); susceptibility to atherosclerosis;¹⁰ and cardiac changes such as bradycardia, tachycardia, and right heart failure leading to sudden death.¹¹

Table 1.

Signs and Symptoms of Sleep Apnea in Adults

Heavy snoring

Bed partner reports periods of non-breathing

Gasping or choking during the night

Excessive daytime sleepiness¹⁴

Frequent arousals during sleep (fragmented sleep)¹⁵

Nonrefreshed sleep

Restless sleep

Kicking and leg movements

Morning headaches

Personality changes such as becoming irritable, or temperamental

Severe anxiety or depression¹⁶

Poor job performance

Loss of alertness

Clouded memory

Intellectual deterioration

Occupational accidents¹²

Impotence

Decreased sex drive

Bruxing¹⁷

Dry mouth upon awakening

Scratchy throat

Alcohol use especially before bedtime

Sedative hypnotics needed to sleep

Regular use of antihistamines

Excessive weight

Age of the patient (generally increases with age)¹⁸

Cardiac irregularities

High blood pressure9

There are also many social reasons to actively treat those who suffer from sleep breathing disorders. These range from husbands and wives who can no longer sleep in the same room, to professional truck drivers who are seeing an increase in accidents and citations for moving violations caused by excessive daytime sleepiness. On-the-job accident rates are also related to sleep apnea.

It has been estimated that the indirect costs of sleep disorders is more than $41 billion a year from lost productivity, $17 billion to $27 billion a year from motor vehicle accidents, $7 billion a year in work-related accidents, and $2 billion to $4 billion a year in home and public accidents.¹² Clearly there is a major national problem that needs to be dealt with in an appropriate fashion.

Because sleep apnea can be associated with many other medical problems, and treatment options are so varied, proper diagnosis and treatment are best handled via a team approach. Members of this team may include a sleep specialist, otolaryngologist, internist, orthodontist, oral surgeon, and general dentist. A dentist should play an active role in screening his or her patients, treating them in conjunction with other sleep specialists, and providing them with follow-up therapy.

Diagnosis: Questionnaires, Exams, and Lab or Home Studies

Screening

Adults

To properly screen patients, one must evaluate them for the presence of any physiologic and behavioral predisposing factors indicating obstructive sleep apnea.¹³ Table 1 lists some of the signs and symptoms that are indicative of an adult who is suffering from sleep apnea. A simple questionnaire can be designed to encompass these points.¹³

Children

Children can also suffer from sleep apnea. Typically such children suffer from growth and development problems. Many of them have underdeveloped maxillas, narrow upper arches, and retruded mandibles. Often they are highly allergic, with their airway completely blocked off due to adenoid and/or tonsillar hypertrophy. If they are already having snoring and breathing problems now, do not ignore them. Table 2 lists some of the signs and symptoms of sleep apnea seen in children.

After having the patient fill out a questionnaire, the practitioner should complete a thorough examination to reveal any anatomical factors. This exam should include the following:

* Complete medical/dental histories;

* Soft tissue/intraoral assessment (this is to include the tongue and the throat);

* Periodontal evaluation;

* Orthopedic/TMJ/occlusal examination;

* Intraoral habit assessment;

* Examination of teeth and restorations;

* Initial dental radiographic survey (to include a baseline lateral cephalometric survey to study the soft palate size, hyoid position, skeletal relationship, and airway opening).

* Diagnostic models;¹³ and

* Facial exam to evaluate neck size, weight, possible retrognathia.

While doing the soft tissue/intraoral assessment portion of an exam, the practitioner should evaluate all three regions of the upper airway.

An obstruction in the nasopharyngeal area is usually caused by turbinate hypertrophy, a deviated septum, or an abnormal growth such as a polyp. Although documenting a problem in this region is the job of an otolaryngologist, a dentist can at least check the patient to see if he or she has a patent nasal airway. The patient should hold a finger over one nostril at a time and breathe in.

When evaluating the oropharyngeal region, the practitioner should first check for hypertrophy in the tonsils. Then check the size and position of the tongue as it relates to the soft palate. Finally, look at the size and drape of the soft palate and the uvula. When the soft palate is excessively long, there is a good chance that the patient will suffer from an oropharyngeal blockage.⁸

An obstruction in a hypopharyngeal airway space is harder to detect through oral observation alone. When motor nerve activity stops during REM sleep, the tongue can drop back against the posterior pharyngeal wall and block the airway. Cephalometric films can give some information on whether an airway is likely to be blocked.²¹

A new component of the physical exam has been developed called the chin press/tongue curl maneuver. This maneuver is based on the changes that occur in the position of a patient's mandible and temporomandibular joint during sleep. During sleep, the patient's mandible and TMJ usually go into the most retruded position. When this occurs, the tongue can drop back against the posterior pharyngeal wall and block the airway. The chin press attempts to replicate this sleep event by guiding the mandible and TMJ into the most retruded position while the patient is supine or reclined in the exam chair.^22,23 This maneuver is performed as follows:^22,23

* Place the patient in a supine position and instruct him or her to maintain gentle occlusal contact while performing deep nasal respirations. In this occlusal relationship, the degree of respiratory effort during both inspiration and expiration is evaluated. This is considered the baseline respiration with which the chin press/tongue curl respirations are to be compared. If there is difficulty with respiration during this baseline portion of the test, the most likely cause is a nasal airway obstruction.

* With the patient's mandible relaxed, apply gentle pressure on the chin to retro-position the mandible and have the patient close. The goal is to place the TMJ into a centric relation position. The patient is then encouraged to relax his or her tongue and pharyngeal muscles and asked not to prevent any obstruction in the posterior pharyngeal region that may occur during this part of the procedure.

* During this manipulation, the patient is instructed once again to perform deep nasal inspirations and expirations. The responses are graded as follows: no obstruction = 0, partial obstruction = 1, and complete obstruction = 2. The greatest degree of obstruction during inspiration or expiration is used as the scoring response.

* Next, the tongue curl enhancing maneuver is performed. This consists of the same manipulation performed in the chin press with the following addition. The patient places the tip of his or her tongue to the most posterior part of the hard palate. This further retro-positions the mandible increasing the likelihood of obstruction during respiration. The patient again performs deep nasal inspirations and expirations. The responses are again graded in the same manner.

Table 2.

Signs and Symptoms of Sleep Apnea in Children.

Hyperactivity¹⁹

Poor concentration

Abnormal skeletal-facial developmental

Hyponasal quality to their voice

Noisy breathers

Obesity

Frequent upper airway infections

Earaches

Nocturnal mouth breathing²⁰

Snoring

Restless sleep

Nightmares

Night terrors

Headaches

Chronic runny nose

Magnetic resonance imaging studies clearly show an airway obstruction occurs when the chin press/tongue curl maneuver is performed on some patients.^22,23 This maneuver has also been shown to correlate with the degree of severity on the nocturnal polysomnogram. It is important to recognize, however, that a negative chin press/tongue curl does not rule out a diagnosis of sleep apnea.^22,23

Diagnosis of Sleep Apnea

Screening patients by asking them questions, evaluating their medical histories, and performing an intraoral examination should enable a practitioner to make a decision on whether the patient suffers from apnea. If a practitioner suspects that a patient may be experiencing apneic episodes, he or she should refer that patient to a physician immediately. Either a sleep specialist, otolaryngologist, or internist can make sure the patient receives a complete medical work-up and sleep test.

Even after a thorough evaluation by the dentist and the physician, a definitive diagnosis of obstructive sleep apnea can only be accomplished by a sleep test called a polysomnogram. During sleep, a polysomnogram measures ventilation, gas exchange, cardiac rhythm, and the number and length of apneic episodes; assesses oxygen saturation; determines sleep stages; and detects arousals. In the past, this test could only be done in a hospital sleep clinic. Today, there is mobile sleep technology that allows the patient to take this test in the comfort of his or her home.

Treatment

It has been said that the best method of treatment is prevention. The dentist can play a role in both the prevention and treatment of snoring and obstructive sleep apnea.

Dentofacial Orthopedics

Early detection of structural abnormalities in the developing child affords the opportunity to intervene with functional therapy, possibly preventing eventual obstructive sleep apnea development. For example, after a thorough orthopedic evaluation, the dentist may then decide to use orthopedic appliances to direct and control a child's growth. Arch development, mandibular repositioning, and controlling vertical dimension may create the intraoral volume needed to accommodate the tongue and prevent its compaction into the hypopharynx.²⁴

Many treatment methods have been tried over the years to treat snoring and obstructive sleep apnea. To date, three approaches are most effective. They are continuous positive airway pressure, surgical techniques, and the use of intraoral appliances. Regardless of the technique used, most patients benefit if a few general behavioral measures are followed.

General Behavioral Measures¹

* Lose weight. People with severe sleep apnea are often overweight. Loss of weight will result in reduced adipose tissue volume in the upper airway, decrease the load on the chest wall and abdomen, and improve respiratory muscular efficiency. In mild cases, weight reduction alone may result in a cure. In other cases it enhances the effects of additional therapy.

* Sleep on one's side. Many studies have shown that patients who sleep on their backs have a significantly higher level of sleep disturbance. It is believed that sleeping in the supine position causes a gravitational pull on the tongue forcing it to come in contact with the posterior pharyngeal wall. Therefore, any technique that keeps one sleeping on his or her side could be beneficial.²⁵

One technique is a positional sleep shirt that has a long tube sewn into it. Every time a patient attempts to roll onto his or her back, he or she hits the tube. This forces the patient back onto the side or stomach.

* Avoid alcohol within two to three hours of bedtime. Alcohol is a central nervous system depressant and changes motor activity in the muscles that control normal inspiration. These changes include relaxation of the walls of the upper airway causing it to collapse.²⁶

* Avoid certain pharmacological agents. Benzodiazepines, narcotics, barbiturates, and testosterone have all been reported to affect the occurrence of apneic episodes. For example, Flurazepam has been shown to worsen apneic episodes in patients who already suffer from this disease and trigger apnea in patients who have no history of the problem.²⁷

Treatment Methods

Continuous Positive Airway Pressure

This technique involves wearing a mask tightly over the nose during sleep. Pressure from an air compressor forces air through the nasal passages and into the airway. This forced air creates a pneumatic splint, keeping the airway open and allowing the person to sleep normally. This is a highly effective therapy and is the most common approach for moderate and severe apnea patients. When it is accepted and used regularly by the patient, it is 100 percent successful at stopping snoring and obstructive sleep apnea.³

Surgical Approaches

* Tracheotomy. Surgical treatment of obstructive sleep apnea began with the tracheotomy, which has a 100 percent success rate because it completely bypasses all the sites of upper airway obstruction. This treatment is rarely done today because it is so extreme. When it is done, it does result in an immediate relief of symptoms.

* Nasal reconstruction. A nasal obstruction causes a patient to mouth breathe. When one opens the mouth to breathe, the mandible rotates back and sometimes allows the base of the tongue to drift posteriorly and block the airway. A nasal obstruction also eliminates the use of continuous positive airway pressure as a choice of treatment. Surgical procedures to clear the nasal airway are rendered in order to correct turbinate hypertrophy, septal deformities, and alar collapse, and to remove tumors or polyps.

* Uvulopalatopharyngoplasty. This procedure was introduced by Ikematsu in 1964 and later by Fujita in 1981. This surgical procedure enlarges the pharyngeal air space by excising the soft tissue of the palate, uvula, tonsils, and posterior and lateral pharyngeal walls. When the airway obstruction is only at the oropharyngeal level, this procedure can be quite successful at stopping snoring.²⁸

* Laser-assisted uvulopalatopharyngoplasty. This procedure is a modification of the uvulopalatopharyngoplasty surgery. It is accomplished using lasers and is considered a less invasive procedure. It is commonly used to resculpture the soft palate.

* Orthognathic procedures. The position of the hyoid complex, mandible, and tongue, and the size and position of the maxilla all play a role in an obstruction at the oropharyngeal and hypopharyngeal level. The goal of an orthognathic surgical approach would be to make more room for the tongue and/or take the base of the tongue away from the posterior pharyngeal wall.²⁹

In patients with a mandibular deficiency, surgical advancement to a normal occlusal relationship can bring the base of the tongue away from the posterior pharyngeal wall. When both a maxillary and mandibular deficiency exist, a bimaxillary advancement surgery will provide more physical room for the tongue as well as increase anterior tension on the tongue musculature.²⁴

Patients with normal dental occlusion who need no additional tongue space can undergo a procedure called an anterior inferior genial osteotomy. The genial tubercle is the site of the attachment for the genioglossus muscle. In this procedure, only this part of the mandible is advanced anteriorly. This pulls the tongue forward to improve the hypopharyngeal airway.²⁴ Various procedures have also been designed to reposition the hyoid bone and thereby advance the base of the tongue.³⁰

Dental Appliances

Numerous appliances are available to treat snoring and obstructive sleep apnea. They can reposition the tissues by lifting up the soft palate, bringing the tongue forward, or lifting the hyoid bone. As they reposition, some appliances also stabilize these tissues, preventing airway collapse. Appliances can also increase muscle tone. Specifically, there is an increase in pharyngeal and genioglossus muscle activity.^31,32

Variations in design range from the method of retention, the type of material being used, the method and ease of adjustability, the ability to control the vertical dimension, differences in mandibular movement, and whether the appliance is lab-fabricated or made in the office.³² The appliance design chosen will depend upon the practitioner's knowledge of these variations and the oral conditions of the patient.

Decision-Making

Clearly, there are many ways to treat obstructive sleep apnea. Which method is best depends upon the severity of the patient's medical risk, the patient's anatomy, the efficacy of the different methods, the cost of each method and the desires of the patient.

For example, although surgical treatment with a tracheotomy is 100 percent effective, with time, a number of complications can result. They are tracheal site infection, physiological problems, granuloma formation, chronic irritation, uncontrolled secretions, bronchial infections, and eventual stenosis.³³ Even more important is the fact that this type of therapy is unwanted by most patients as they cannot accept the idea of a permanent tracheotomy.

Even continuous positive airway pressure, which is considered the therapy of choice by most physicians and is highly effective, is not for everybody. In fact, daily compliance by patients using this treatment is less than 50 percent. The negatives to this treatment are that it is uncomfortable, inconvenient, restricts a patient's movement, and dries out the airway mucosa.³

When the airway obstruction is only at the oropharyngeal level, a uvulopalatopharyngoplasty or a laser-assisted uvulopalatopharyngoplasty can be quite successful in stopping snoring and apnea. However, if the obstruction is below the oropharynx, this type of surgery is contraindicated. Most clinical investigations indicate that the success of this surgical approach to correct obstructive sleep apnea is less than 50 percent.²⁸ This is the case because the level and cause of the obstruction is often misdiagnosed. Removing some of the vibrating tissues may resolve snoring but it does not prevent an obstruction by the base of the tongue. Surgery is not without its complications. Postoperative stenosis, significant postoperative pain, and infection are possible complications of this approach.²⁸ Patients also often experience nasal regurgitation after this surgery. Furthermore, the morbidity rate for a uvulopalatopharyngoplasty is quite high.

Orthognathic procedures have been shown to be quite successful. In fact, Waite and colleagues have shown a 96 percent improvement in the apnea index when bimaxillary advancement surgery was the primary surgical procedure.²⁹ However these surgeries are quite invasive and most patients when given a choice will opt for a nonsurgical approach.

Research has shown that many dental appliances are quite effective and can be considered an alternative when choosing a treatment modality. Dental appliances offer several advantages over other therapy choices. They are inexpensive, noninvasive, easy to fabricate, reversible, and quite well accepted by patients.

The basic indications for dental sleep appliances are to treat primary snoring and mild to moderate obstructive sleep apnea. Appliances are particularly appropriate for those patients who cannot tolerate continuous positive airway pressure. When surgery is contraindicated or the patient is unwilling to go through a surgical procedure, appliance therapy may also be appropriate.³⁴

The treatment objectives for dental appliance therapy are to stop or reduce snoring, resolve the patient's obstructive sleep apnea problems, get a higher amount of oxygen into the system, and eliminate excessive daytime sleepiness, allowing the patient to function normally.

It should be remembered that fabrication of an appliance in an attempt to stop snoring could cause the practitioner to overlook a serious medical problem such as a nasopharyngeal tumor.

Also, appliances do not work all of the time regardless of the appliance chosen. Although appliances work well for blockages that occur in the hypopharyngeal region, it is possible for there to be an obstruction in more than one region at the same time. When this occurs, the effectiveness of an appliance will be diminished. Even under the best of circumstances, a practitioner may end up trying two, three, maybe even four appliances before finding one that works well and is accepted by the patient.

Based on a complete screening and a thorough examination, any patient who snores and is suspected of being an apnea victim should be medically evaluated before the practitioner proceeds to place an appliance. Armed with the dentist's screening and oral examination results, along with their own physical evaluation, the physician can move the patient to the next appropriate step in treatment This may include immediate use of continuous positive airway pressure in a patient who is severely compromised and a referral to a sleep lab for a complete polysomnogram. A polysomnogram is the only technique to make the distinction between someone who snores and someone who is suffering from apnea.³⁵ Even when a patient is not suspected of suffering from apnea, it is a mistake to make an appliance without a proper medical evaluation.

Informed Consent, Follow-Up Questionnaire, Common Side Effects

Before placing a dental appliance, the practitioner should provide the patient with an informed consent. This consent should explain all the ramifications of utilizing dental appliances for the treatment of snoring and apnea.

When the patient is suffering from obstructive sleep apnea and is being treated with an appliance, a follow-up polysomnogram to evaluate the effectiveness of the appliance should be ordered. The patient should not be referred for the second sleep test until there are subjective improvements. When the patient's excessive daytime sleepiness is gone, energy level is back, and snoring has stopped, it is time for the second sleep study.

Periodic evaluation and adjustment of appliances is a must. Most of them need to be titrated to establish the exact mandibular position needed to correct the patient's snoring and apnea. The dentist will also need to make sure that the patient's occlusion remains stable. Even though most of the appliances cap the teeth, anterior flaring and other occlusal changes can still occur. If they are kept clean, these appliances will generally last a long time. However, most of them will need to be replaced from time to time as patients break or wear through them.³²

During the follow-up visits, the practitioner needs to ask specific questions to evaluate how the patients are progressing. Questions include:³²

* Can you sleep with the appliance?

* Is it comfortable?

* Are your teeth sore in the morning? For how long?

* Is your bite different from normal in the morning?

* Have you seen any permanent changes in your bite?

* Does your jaw hurt? When? For how long?

* Does your bed partner hear you snore? If so, was it as loud as usual?

* Was any gasping or snoring observed?

* Did you appear to stop breathing at any time?

* Was your breathing any different from prior to the appliance placement?

* Do you wake up often?

* Do you feel more refreshed in the morning?

* How do you feel the rest of the day?

* Do you have any other comments or concerns?

Some of the common side effects that patients may experience with the use of sleep appliances are excessive salivation, discomfort in the teeth, dry mouth and tissue irritation from mouth breathing, temporary disharmonies in the bite, and some pain in the joints. Uncommon complications include TMJ dysfunction and permanent occlusal changes.

Summary

An awareness that snoring is an important sign that a serious medical problem may exist, and the knowledge that one out of every 10 people snore, should be enough information to prod the medical community into action. Dentists can play a role in both the recognition and treatment of sleep disorders. They can start by revising the standard medical and dental questionnaires. The right questions on the questionnaire can trigger a discussion on snoring and apnea. A few questions that can be added are: Do you snore? Do you wake up tired in the morning? Do you dream? Do you become extremely tired or fall asleep during the day? Are you overweight? Can you breathe through your nose? Do you drink alcohol before bedtime?

The practitioner can re-evaluate how he or she does an intraoral examination. He or she should spend the time to look at the oropharyngeal airway space, the hypopharyngeal airway space (via the chin press/tongue curl maneuver), the size of the tongue, the position of the mandible, the vault of the palate, and the nasal airway.

Most important, because sleep apnea can be associated with many other medical problems and treatment options are so varied, proper diagnosis and treatment are best handled by a team approach. The dentist should work closely with other health care professionals. Referral of patients to a physician indicates the dentist's desire to make certain that the patient receives the best care possible.

Author

Rob W. Veis, DDS, is vice president of Space Maintainers Lab, a dental laboratory that makes sleep appliances.

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