Screening for Sleep Problems

Dental hygienists are trained to evaluate the entire patient and not just the oral cavity. Even with a limited appointment time, dental hygienists can recognize traits, characteristics, and behaviors that predispose patients to a variety of systemic conditions, including sleeping disorders. For example, when greeting your 10:00 am patient, you observe that the 60-year-old man’s head is down, his eyes are closed, and by the sound of his breathing, he is obviously napping. You call his name. Startled, he looks up and makes eye contact with you. As you review his medical history, you notice he is overweight with a thick neck circumference. During the intraoral assessment, his large tongue and uvula block the back of the oral cavity, impeding your view of the throat. His medical history reveals coronary artery disease and hypertension. Is there enough information to diagnose this patient with a sleeping disorder? Probably not, but this patient exhibits some risk factors of a sleeping disorder, such as obstructive sleep apnea (OSA). Dental hygienists are becoming more familiar with screening questionnaires and assessments of the oropharyngeal anatomy that can be used to further evaluate the patient. If the patient presents with risk factors, the dental hygienist should make the dentist aware and possibly suggest a referral to the patient’s primary care physician for further evaluation and testing.

WHAT IS OBSTRUCTIVE SLEEP APNEA?

OSA is a sudden blockage of air in the upper airway that occurs during sleep. These repeated pauses in breathing (apnea episodes) occur during sleep as the muscles of the body relax. Daytime sleepiness, fatigue, and snoring are symptoms. Many times patients are unaware of these apnea episodes and remain undiagnosed for years. OSA can cause other systemic health problems, such as arrhythmias, atherosclerosis, congestive heart failure, coronary artery disease, diabetes, hypertension, pulmonary hypertension, and stroke.^1–3 OSA involves several components of the pharyngeal airway anatomy including the base of the tongue, soft palate, uvula, adenoids, tonsils, and nose. Nearly 80% of all moderate to severe cases of OSA in middle-aged men and women are undiagnosed.⁴ The dental professional can play an important role in the early detection, referral, and treatment of OSA.

OSA symptoms are noticeable during an oral assessment. A narrow palate can increase the risk by reducing the space for the tongue, causing crowding of the pharyngeal airway and reducing the nasal space. Enlarged uvula, tonsils, and adenoids may also lead to obstruction of the upper airway. Occlusal tendencies, such as a retrognathic profile and class II occlusion crossbite, also contribute to OSA. Additional intraoral features include dental attrition caused by bruxism and erosion related to gastroesophageal reflex disorder (GERD). Edentulism is also considered an OSA risk factor. The loss of vertical dimension resulting from the missing teeth may lead to the collapse of pharyngeal soft tissues.

Xerostomia is also a risk factor due to episodes of an open mouth during the night.^5,6 Obesity is a symptom and 70% of patients with sleep apnea are obese.⁷ Studies show that neck circumference greater than 17 inches for men and 16 inches for women also raises the risk of OSA.⁸

The definitive diagnosis for OSA is achieved through a sleep study or polysomnogram that is typically performed in a sleep lab. Patients are required to spend approximately 8 hours at the lab under observation. During a sleep study, biophysiological changes are documented and recorded. The sleep study evaluates oxygen levels; snoring; respiratory effort; nasal and oral airflow; brain waves by electroencephalogram (EEG); heart activity by electrocardiogram (ECG); and eye, jaw, and leg movement through electromyogram (EMG). The sleep study measures apnea and hypopnea episodes. Apnea is a cessation of airflow of the upper airway lasting at least 10 seconds. Hypopneas are partial obstructions resulting in a 20% to 50% decrease in airflow. Both cause a decrease in oxygen and increase in carbon dioxide in the blood. The polysomnography technician closely monitors the patient during sleep, recording and evaluating the biophysiological changes that occur. If the polysomnography test indicates OSA, patients are given an apnea-hypopnea index (AHI) score to classify the severity. A moderate to severe AHI score requires treatment.

SCREENING TOOLS

Screening tools can be utilized during the dental hygiene appointment to identify patients at risk of OSA. These include easily administered patient questionnaires and visual intraoral assessment. The Epworth Sleepiness Scale, a simple questionnaire regarding daytime sleepiness, is used to identify high risk patients (Table 1).⁹ A score is derived to confirm the patient’s risk of OSA and encourage the patient to schedule a more definitive examination, such as a full sleep study. STOP and STOP-BANG are acronyms used to identify significant risk factors of OSA, including snoring, fatigue, observed apneas, high blood pressure, BMI greater than 30, age (middle aged), neck circumference, and gender (Table 2).^10,11  Visual intraoral assessments that measure soft tissue obstruction through a grading system are available, such as the Friedman, Fujita, and Mallampati scoring systems.^12–16

One of the most common screening methods, the Mallampati classification, is used by anesthesiologists to identify patients who may be at risk for a difficult airway intubation during general anesthesia. Research has confirmed the usefulness of this scoring system in identifying patients who may also be at risk for OSA.¹⁵ Currently other health professionals, such as pulmonologists, physicians, and respiratory care practitioners, use this screening tool. The airway is classified by examining the oral cavity as the patient opens his or her mouth and extends the tongue. The dental hygienist can evaluate the opening of the oropharynx by comparing the size and shape of the soft palate and uvula to the back of the throat. Mallampati classifications of III or IV indicate the patient may be at risk for OSA. These classification systems are not used to diagnose OSA, but they do provide signals that additional testing is needed and help raise awareness among patients.

Not all patients exhibit the classic signs and symptoms of OSA. Women may present with symptoms different from the traditional symptoms of loud snoring, thick neck circumference, and daytime sleepiness. Women may experience symptoms such as morning headaches, fatigue, and mood disturbances that may not prompt further testing for a sleep disorder.

TREATMENT

A variety of treatment options are available for patients with OSA. Multidisciplinary approaches may include continuous positive airway pressure (CPAP) devices, oral appliances, behavioral treatment, surgery, and/or adjunctive treatments.¹⁷ These options are based on the severity of the condition, patient’s age, medical history, and the cause of the obstruction. The most common treatment is the CPAP machine, which is used during sleep. A mask attached to a ventilating device is worn and delivers a continuous air flow to open the airway during sleep. Some patients refuse to use the CPAP device for various reasons. The pressure of the mask may be uncomfortable and the continuous airflow may cause xerostomia or even make the patient feel claustrophobic. For patients who do not accept the CPAP, alternative treatments should be considered. Secondary medical treatment for OSA includes oral appliances, surgery, and behavioral modifications. The anterior mandibular positioning (AMP) device is an oral appliance designed to reposition the mandible in a forward position. The device pulls the back of the tongue forward, helping to open the airway. Appliances are custom made and vary in design. When oral appliance therapy is used, a secondary poly somnography test is required to determine success of the treatment.

Side effects may occur with the use of AMP devices including tooth movement, excessive salivation, and temporomandibular joint pain that may limit their use. In severe cases, these appliances may be used in conjunction with CPAP. Surgical procedures may be recommended, including adenotonsilectomy (removal of adenoids and tonsils); uvulo palato pharyn geal plasty, which reduces the soft tissue in the oropharyngeal region; and maxilla mandibular advancement, which surgically lengthens the jaw. In very severe cases, a tracheotomy can be recommended, which will bypass the airway occlusion and alleviate the obstructive apneas. This treatment is usually done only if all other modalities have failed.

CHILDREN AND OSA

Sleep disorders also affect children. OSA can affect a child’s development and behavior and should be diagnosed and treated early. Enlarged tonsil tissues are one of the main causes. The increased size of the tonsil tissue may result in blockage of the airway and cause interruptions in breathing during sleep. Children with craniofacial anomalies, such as retrognathia or micrognathia, midface hypoplasia, mandibular hypoplasia, and macroglossia, may also be at risk for OSA.¹⁸ Risk factors among children include snoring or family history of OSA, cerebral palsy, muscular dystrophy, Down syndrome, sickle-cell disease, mouth breathing, nasal obstruction, and obesity.¹⁹ Nighttime symptoms include snoring, bizarre sleeping position, bedwetting, and sweating. Daytime symptoms include aggressive behavior, anxiety, hyperactivity, inattentiveness, learning difficulties, poor grades, morning headaches, mouth breathing, and a history of recurrent illness.^20,21

Polysomnography sleep studies are also used to diagnose OSA in children. Surgery is the primary treatment in this patient population. Adenotonsilectomy results in eliminating OSA in 75% to 100% of cases.²⁰ Oral appliances, such as the rapid maxillary expansion device (palatal expander), may also be used to allow the tongue more room in the oral cavity and reduce airway obstruction. Re-evaluation using polysomnography after surgery or other interventions may be necessary to determine the success of treatment.

ROLE OF THE DENTAL HYGIENIST

By completing a comprehensive exam, dental hygienists can provide a valuable service to their patients by incorporating the OSA Essentials for Dental Hygienists (Table 3), into their routine evaluation of every patient. Depending on the screening tools and methods used, the amount of time added to the dental hygiene appointment will fluctuate from patient to patient. Most patients show symptoms of disease before they are formally diagnosed. Nondescript symptoms tend to arise long before patients are motivated to pursue a medical diagnosis. All health professionals, including dental hygienists, should be participating in the screening and referral of patients with sleep disorders.²²

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From Dimensions of Dental Hygiene. July 2012; 10(7): 56-59.