Goodlettsville Dental Services

Dentists Against Drowsy Driving

“Dentists Against Drowsy Driving” was established by the American Academy of Dental Sleep Medicine (AADSM) in November 2008 to increase awareness among healthcare practitioners and the public about the alarming healthcare risks and economic impact of the largely undiagnosed and untreated sleep-related breathing disorders (SBD) such as the potentially life-threatening obstructive apnea with daytime hypersomnolence syndrome (OSAS) in the general population.

According to the Institute of Medicine’s 461 page report released in April 2006 entitled “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem” (http://nap.edu), 50-70 million Americans suffer from chronic sleep disorders, the estimated prevalence of OSAS being 4 to 7% of the U.S. population. Daytime hypersomnolence alone costs $150 Billion annually in lost productivity and mishaps, and another $48 Billion in medical costs related to motor vehicle accidents that involve drowsy drivers. 20% of all serious car crashes are associated with daytime hypersomnolence, independent of alcohol.

What are Sleep-Related Breathing Disorders?

Sleep-related breathing disorders (SBD) include the spectrum of snoring, upper airway resistance syndrome, and obstructive sleep apnea syndrome (OSAS). SBD are caused by repetitive collapse or blockage of the upper airway while asleep, that can result in reduced blood oxygen levels to the brain, heart, and other vital organs. Snoring is the resultant “warning bell” of partial or impending airway collapse, whereas OSA results from a complete airway obstruction lasting greater than ten seconds. In addition to daytime sleepiness, OSAS may have other daytime symptoms of cognitive impairment that include memory loss, morning headaches, irritability, depression, decreased libido, and impaired concentration. Left untreated, OSA can cause hypertension, strokes, cardiovascular dysrhythmias, myocardial infarction, and sudden death while asleep.

Diagnostic testing

SBD including OSA are diagnosed by overnight polysomnography, a sleep study usually performed in an accredited sleep laboratory and interpreted by a sleep physician. Unfortunately, the vast majority of OSAS is undiagnosed and untreated, partly because there are not enough sleep physicians and dentists involved with dental sleep medicine.

There are 176,634 dentists who are members of the ADA (2005 survey), versus 7,272 pulmonologists, 15,626 neurologists, and 12,471 otolaryngologists who are members of the AMA (2008 survey). However, there are only 1,265 dentists versus 6,700 sleep physicians who are members of the AADSM and the American Academy of Sleep Medicine (AASM), respectively. Clearly, the potential number of dentists far exceeds the number of sleep physicians for addressing the healthcare manpower shortage aspect of this unmet public health problem in terms of providing treatment of OSAS.

Oral Appliance Therapy

Dentists have pioneered the scientific research and clinical development of Oral Appliance Therapy (OAT) for SBD. OAT involves the selection, fabrication, fitting, adjustments, and long term follow-up care (and management of potential complications such as malocclusion and temporomandibular joint (TMJ) dysfunction) of custom-designed oral devices, worn only during sleep, to reposition the mandible and tongue base anteriorly to enlarge and stabilize the oropharyngeal airway. Based in large part on the successful outcomes of 87 evidence-based scientific studies that includes 15 Level I and II randomized controls trials, the AASM published updated “Practice Parameters” that now cites OAT, which should be performed by qualified dentists, as a 1 st line treatment for selected cases of mild to moderate OSA ( Sleep 2006:29;240-262).

In comparison to the traditional gold standard treatment Continuous Positive Airway Pressure (CPAP) that is usually delivered via a nasal mask while asleep, OAT is better tolerated in terms of required nightly use. Like CPAP pressures, the amount of mandibular and tongue base advancement can be titrated to patient comfort limits (e.g., of TMJ) and/or therapeutic efficacy. If subtherapeutic, OAs may also be used concomitantly with CPAP, thereby allowing lower therapeutic pressures that may be more tolerable. If nontolerable, OAs may also be predictors of mandibular advancement surgery.

Other treatments

In addition to OAT that is performed by dentists, other OSAS therapies that are managed by sleep physicians include CPAP, positional therapy, weight reduction, and a reduction of late evening consumption of sedative-hypnotic medications and alcoholic beverages. Upper airway surgery is generally indicated when these conservative therapies are non-applicable, unsuccessful, or intolerable. Surgery may be an effective treatment for SBD, but only if performed competently and on correctly identified specific anatomic sites that contribute to upper airway obstruction, which varies between different patients.

The dental specialty of oral & maxillofacial surgery (OMFS) has pioneered the development of jaw, i.e., maxillomandibular advancement (MMA) surgery, which is highly therapeutic for selected cases of moderate to severe OSA. MMA permanently advances the soft palate and tongue base (suspended from the maxilla and mandible, respectively) to enlarge and stabilize the entire velo-oro- hypopharyngeal airway and can be combined safely with adjunctive extrapharyngeal procedures in a single-staged operation. There are minimal risks of airway embarrassment due to edema in the immediate post-operative period or recurrent OSAS due to cicatricial scarring and contracture, because the tissue dissection and bony osteotomies are performed outside the pharyngeal airway lumen ( Chest 1999:116; 1519-1529).

Dental-medical team approach

Except for OAT and some types of upper airway surgery that are performed by dentists and OMFS, all other OSAS therapies are managed by sleep physicians. Furthermore, the diagnosis of SBD, particularly the potentially life-threatening medical disorder OSAS, as well as the differential diagnosis of narcolepsy, periodic limb movements of sleep, insufficient sleep syndrome, and other medical conditions that also exhibit daytime hypersonmolence, must be determined by sleep physicians. This medical-dental practice protocol (advocated by the AADSM and the AASM) must continue to be implemented for the health and safety of our patients (and to comply with our state licensure boards). Simply put, this scope of practice is just good (sleep and dental sleep) medicine.

Why should dentists become more involved?

Dentists are becoming more involved with sleep physicians as part of a harmonious integrated multidisciplinary team approach for the treatment of the medical disorder OSAS for several reasons. First, given their relatively large numbers, dentists are challenged to share altruistic responsibility in responding to the alarming healthcare risks and economic impact of the largely untreated OSAS in the general population. Second, all dentists have knowledge and expertise in upper airway anatomy and physiology, which is essential to understanding and treating OSAS. Third, every dentist is skilled in occlusal splints and, thus, is capable of performing OAT, which is a recognized 1 st line treatment for mild-moderate OSAS. Fourth, dentists understand occlusion and TMJ and, thus, are best prepared to manage potential side effects of OAT. Fifth, OMFS have expertise in orthognathic and, thus, the highly therapeutic telegnathic MMA surgery for OSAS.

How can the public help?

The general population should be aware that SBD such as snoring and OSA are very common medical disorders. They are more common in males and worsen with advancing age and weight gain. The hallmark sign of OSA, a potentially life-threatening disorder, is snoring while asleep and the most common symptom while awake is excessive sleepiness. Daytime sleepiness is a major health risk not only to the individual that may have OSA, but also to others such as while driving motor vehicles on the highways. Anyone who exhibits snoring with associated “gasping for air” while asleep as well as daytime sleepiness (eg., “falling asleep at the wheel” while driving) probably has OSA and should, therefore, be referred to a sleep physician for diagnosis and treatment. You can also alert your dentist of these possible OSA signs and symptoms for referral to a sleep physician for diagnostic testing, and then back to your dentist for OAT in selected cases.