The Case for Providing Dental Sleep Medicine is Overwhelming

This Life-Saving Expertise Is One Every Dentist Should Master

Most dentists in the United States do not treat obstructive sleep apnea. In fact, they don't even screen their patients to determine if they exhibit any of the telltale signs of the disease, such as loud snoring, daytime sleepiness, and cognitive impairment.

Yet obstructive sleep apnea (OSA), arguably, contributes to the deaths of far more Americans annually than does oral cancer, which virtually every dentist checks for during each and every patient examination.

Patients with OSA are at heightened risk for heart disease, stroke, diabetes, chronic acid reflux, and erectile dysfunction. They are also far more likely to be in a fatal automobile accident due to drowsy driving.

So why do so few dentists treat sleep apnea?  The answer, in short, is that they are misinformed.

Dental Sleep Medicine has gotten a bad – and mostly undeserved – reputation. Some dentists mistakenly view it only as a revenue-generating add-on that distracts from their core mission of maintaining and restoring oral health.

Other dentists needlessly fear sleep medicine, worried that it unduly exposes them to lawsuits related to TMJ injuries and similar types of malpractice claims.

Still other dentists have been put off by the questionable marketing and teaching methods of some dubious dental sleep medicine programs, which can come across as far more dedicated to generating tuition income for themselves than to educating dentists on the proper, safe methods of treating sleep apnea patients.

But the explosion of obese adults – who are more prone than the general population to develop sleep apnea – is an undeniable summons to all dentists to reexamine the facts pertaining to OSA and the role that dentists can play in helping to address this growing public health crisis.

To be sure, based on the prevalence of sleep apnea among the population at large, it is probable that 10% or more of a dental practice's patients are at serious health risk due to sleep apnea and don't even know it.

Working with Physicians

Working closely with sleep physicians, who by law must make the initial diagnosis of sleep apnea, dentists are uniquely suited to offer patients a custom-fitted oral appliance that many patients prefer to being tethered all night to a CPAP (continuous positive airway pressure) machine. In addition to being more comfortable and easier to wear, oral appliances have the advantage of being portable and quiet.

When dentists know the whole truth about sleep medicine, some may still decide to forgo the training necessary to provide sleep appliances to their patients.

More likely than not, however, armed with the facts, dentists and their team members will see the manifold benefits – to their patients and their practices – of adding dental sleep medicine to their existing services.

Dentists who attend a bona fide sleep medicine course arrive with many questions and some reservations. However, experience amply demonstrates that once well-trained dentists add sleep medicine to their practices, their reservations quickly evaporate and they are left asking only a single question: Why didn't I start sooner?

The Best Offensive Lines in the NFL Couldn't Stop Him – But Sleep Apnea Did

As quarterback of the New York Giants, Phil Simms won two Super Bowls and completed 33,462 passing yards during his 14-year career in the National Football League.

His record, undoubtedly, would have been even more impressive were it not for Hall of Fame defensive end Reggie White, Number 94, who sacked Simms 15.5 times during Simms's career, sending the Giants quarterback to the turf more often than any of Reggie's other notable on-field prey, who included Troy Aikman, John Elway, Jim Plunkett, and Joe Montana.

For those readers who are not football fans, the point is that Reggie White was among the greatest defensive players of all time; a gifted athlete who consistently broke through the offensive line and struck fear into the hearts of some of football's most celebrated quarterbacks and their coaches.

By the time Reggie hung up his jersey in 2000, having played a combined 15 seasons for the Philadelphia Eagles, Green Bay Packers, and Carolina Panthers, he held the record for the most NFL sacks ever, with 198.

On the playing field, Reggie was an unstoppable terror; off the field, he was an ordained Baptist Minister, a bible student, and a very devout man of peace.

On December 26, 2004, at the age of 43, Reggie died in his sleep after experiencing breathing problems. The county medical examiner ruled the official cause of death was a cardiac arrhythmia stemming from complications related to sarcoidosis. Reggie's sleep apnea was a contributing factor.

So, too, did OSA hasten the deaths of actress Carrie Fisher, 60, (Star Wars); actor James Gandolfini, 51, (The Sopranos); actor John Candy, 43 (Planes, Trains and Automobiles); the Grateful Dead's Jerry Garcia, 53; and Hawaiian singer Israel Kamakawiwo'ole, 38. 

Other Famous Sufferers

Other public figures known to suffer from sleep apnea include: actor William Shatner (Star Trek); talk show host Regis Philbin; Secretary of Energy and former Texas Governor Rick Perry; basketball great Shaquille O'Neal; former American Idol judge and record producer Randy Jackson; comedian/magician Penn Jillette; and author Anne Rice (The Vampire Chronicles).

Even William Howard Taft, president of the United States from 1909 to 1913, is believed to have developed OSA; often falling asleep during the day, snoring, and battling high blood pressure – another common condition related to sleep apnea.

In Reggie White's case, it's quite possible that a dental sleep appliance would have prevented his death. 

Reggie knew he had OSA and he owned a CPAP machine. But like so many others, he found the CPAP mask too uncomfortable.
On the night he died, Reggie's CPAP machine sat unused at his bedside.

Why A Dentist?

Every organ in the human body and every disease we contract is impacted by the quality and quantity of sleep we get.
After a good night's sleep, we're more likely to look, feel, and function at optimal levels. After a poor night's sleep, our mood, energy, concentration, and appearance all suffer.

String together enough bad, sleep-disrupted nights – such as those associated with obstructive sleep apnea – and we become vulnerable to a chain reaction of health problems, as well as a two-to-seven-fold increased risk for motor vehicle accidents.

OSA is recognized as a chronic medical disease and thus must always be diagnosed and managed by a licensed sleep physician. It's relationship to dentistry stems from the fact that sleep apnea is associated with the soft tissue of the mouth and throat. OSA occurs when the upper airway muscles relax during sleep, obstructing the airway, and causing the sufferer to momentarily stop breathing. These interruptions, which can occur hundreds of times nightly, reduce oxygen levels in the blood and are typically followed by brief awakenings that disturb sleep.

Obstructive sleep apnea is more likely to occur in men, especially those who are overweight and have thick necks, although it impacts men and women of all sizes and ages, as well as children. Smoking, excessive drinking, and the use of sedatives have also been associated with an increased risk of sleep apnea.

The standard of care for patients with sleep apnea is to use a CPAP machine nightly.  But many patients, like Reggie White, won't tolerate wearing a tethered mask the entire night – using CPAP only part of the time or not at all.
FDA-Cleared Dental Sleep Appliances

A safe, widely accepted alternative, is to fit the patient with a so-called sleep appliance, which is worn like an orthodontic retainer or sports mouth guard, and is generally better tolerated than a CPAP face mask. It is dentists who pioneered the use of oral appliance therapy and more than 150 oral appliances have been cleared by the Food and Drug Administration for the treatment of OSA.

To properly fit a sleep appliance requires a skilled, specially trained dentist, who takes impressions of every single tooth and ensures that the patient has hard and soft tissues that will support an appliance. Sometimes a patient seeking a dental sleep appliance will need restorative dental work prior to being fitted.

A variety of for-profit academies offer so-called dental sleep apnea training, although the educational standards used by some of these courses is questionable, as is their dedication to patient safety and well-being. 

Beginning this year, DOCS Education, widely respected for the quality of its curricula and faculty, will add a two-day Master Series: Dental Sleep Medicine course providing exclusive training and treatment protocols available nowhere else. The course will be led by John H. Tucker, DMD, himself a sleep apnea sufferer, who has been educating dentists on the proper and safest dental sleep medicine protocols for more than a decade.

DOCS Education members increasingly report that their patients are asking them – their trusted dentist – to also provide dental sleep therapy, rather than referring those loyal patients to an unfamiliar dentist who offers sleep appliances. 
"Meeting the needs of patients, safely and effectively, has always been our central focus," explains Dr. Michael D. Silverman, president and co-founder of DOCS Education. "In offering our new Master Series: Dental Sleep Medicine course, we are furthering our mission to educate and train dentists so that they can make quality care available to as many people as possible."

Dr. Tucker, a Diplomate of the American Board of Dental Sleep Medicine, is a firm believer in the efficacy of dental appliances for the treatment of sleep apnea. While the standard of care at present continues to recommend CPAP machines for those patients who can tolerate them, Dr. Tucker forecasts that science and clinical experience will inevitably establish dental appliances to be the preferred method of treatment for all OSA patients.

To learn more about the DOCS Education Master Series: Dental Sleep Medicine course, and to register, visit www.DOCSEducation.com/courses. In addition to teaching the scientifically backed protocols relied upon for safety and efficacy, Dr. Tucker will address the variety of myths that have arisen pertaining to dental sleep medicine. Among these is the erroneous perception that dentists who treat sleep apnea are going to cause TMJ problems or otherwise expose themselves to a greater likelihood of malpractice complaints.

The reality, Dr. Tucker explains, is that most TMJ problems actually improve when patients use their dental sleep appliances. Moreover, when a patient is properly diagnosed and treated according to his recommended protocols, Dr. Tucker demonstrates why treating a patient for sleep apnea is safer, and leads to fewer complications, than most common oral health treatments.

In both practicing dental sleep medicine and training other dentists on the optimal dental sleep medicine protocols, Dr. Tucker has witnessed a twofold benefit for patients: First, as noted above, existing dental practice patients are able to be treated for sleep apnea by the same dentists they already know and trust; second, patients who first visit a sleep medicine dentist solely for treatment of their sleep apnea, often find the process so rewarding that they come to trust their sleep dentist for all of their oral health needs.

We Have a Responsibility to Our Patients

Dentists are not oropharyngeal oncologists, yet in keeping with American Dental Association recommendations and dental school training, dentists routinely examine their patients for signs of oral cancer.

The fact that oral cancer is not a condition treated by dentists does not alter the vital role that dentists can play in detecting it and saving their patients' lives.

"Early cancer diagnoses have the potential to have a significant impact on treatment decisions and outcomes, and [the ADA] supports routine visual and tactile examinations, particularly for patients who are at risk…," reads ADA House of Delegates Resolution 85H-2014.

The detection of obstructive sleep apnea should be no less of a priority for dentists, who actually can play a far more substantive role in ameliorating sleep apnea than they can in addressing oral cancer.

The demographics are compelling.

The Oral Cancer Foundation estimates that just shy of 50,000 people are diagnosed with oral oropharyngeal cancer annually, and oral cancer will lead to more than 9,750 deaths a year.

The American Academy of Dental Sleep Medicine pegs the number of adults in the U.S. who have obstructive sleep apnea at 30 million, or more than one out of every ten citizens who are at least 18 years of age.

More Deadly Than Oral Cancer

Exactly how many of those with OSA die annually from stroke, heart disease, diabetes and other sleep-apnea related illnesses is unknown, as is the number of traffic fatalities that result from an OSA driver who is drowsy or asleep at the wheel.

But it is a safe bet that sleep apnea is a factor in at least as many deaths annually as oral cancer, and very likely many times more.

Maintaining and restoring the oral health of patients is what inspires so many dentists to pursue the profession. It is common knowledge that an unhealthy mouth can lead to serious systemic health issues.

So, already, the work of most dentists is life-saving.

But the greatest avoidable life-threatening risk facing dental patients remains, for now, a backwater of the dental profession: treating sleep apnea.

However, there can be no dodging reality. Undiagnosed and untreated sleep apnea contributes to the deaths of thousands, likely tens of thousands, of dental patients a year.

These are mostly premature deaths. 

Moreover, dentists can readily be equipped to safely treat sleep apnea without extensive additional training; with fewer actual legal risks than they already encounter daily; and without disrupting their existing practices.

The overriding question for all dedicated dentists – those who genuinely care about their patients and their profession – is not: "Why should I offer dental sleep medicine?" 

The real question is: "Why wouldn't I offer dental sleep medicine?" 

The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.