As dental hygienists, we take an oath to affirm our personal and professional commitment to improve the oral health of the public, to advance the art and science of dental hygiene, and to promote high standards of quality care. Throughout the last 27 years of practice, my role has evolved into more than just dental hygiene. Being a dental hygienist is my passion, but working in the dental sleep medicine field has become my destiny.
Dental sleep medicine is a field of dental practice that focuses on the use of mandibular repositioning devices to treat sleep-disordered breathing which includes snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA). Dental teams can work together with sleep physicians to screen, assess, and identify optimum therapy for their patients. In recent years, research has linked many health conditions to the oral cavity. Never forgetting the “head” is attached to the “body”, dentistry’s role in healthcare has become interdisciplinary. Dentists and hygienists work alongside physicians to offer quality healthcare for the whole person.
Obstructive sleep apnea (OSA) is the most common type of sleep disordered breathing. It occurs when the soft tissue in the back of your throat relaxes during sleep and blocks the airway, often causing you to snore loudly or gasp for breath. Sleep apnea is a brief cessation of your breathing while you’re asleep. This cessation of breath can typically last anywhere from 10 seconds to over one minute and can occur hundreds of times a night. As a consequence, you spend more time in light sleep and less time in the deep, restorative sleep you need to be energetic, productive and function well the next day. Since sleep apnea only occurs while you’re sleeping, though, many people aren’t aware they have a problem until someone observes and/or complains about their snoring. Sleep apnea can take a serious toll on your physical, mental and emotional health.
So, how exactly can dental hygienists use their talents beyond the periodontium? By screening every single patient for sleep breathing disorders! A recent research study to determine the feasibility of screening for OSA risk in a dental practice concluded that overall, more than half of the subjects screened were high-risk. Dental hygienists typically have a close and trusting relationship with their patients. Our patients visit us often throughout the year, grow close to us and become more like family than patients. The dental hygiene profession is one of compassion, caring and optimal health, so it fits perfectly within our scope of practice to be screening for OSA. We are in a prime position to recognize the signs and symptoms of OSA through questionnaires, medical history, and oral examination. There is compelling evidence that OSA is a significant risk factor for cardiovascular disease, acid reflux, diabetes, metabolic syndrome and a myriad of other common medical conditions.
Many questionnaires are specifically designed to screen for OSA and easy to use. The Epworth Sleepiness Scale (ESS) askes 8 questions analyzing how sleepy you are in certain situations. A score higher than 10 places you at risk for OSA. Another well validated questionnaire is the STOP-BANG, asking about S=snoring, T=tired, O=observed stop breathing, P=blood pressure, B=BMI, A=age, N=neck, G=gender, scoring 3 or more positive answers also places you as high risk for OSA. These are quick and easy screening tools that you can utilize during your hygiene re-care visits.
While examining the patient, we should be looking beyond the mouth. Certain anatomic traits can be contributory to sleep apnea. Is there a large scalloped tongue? Could that mean that the tongue is too big to fit in the mouth? Think about where that tongue goes when the patient is sleeping. As the muscles relax, could the tongue be falling posteriorly into the airway? What about the uvula? Is it inflamed or irritated? Could this be from chronic snoring? Are the tonsils large, perhaps kissing tonsils? Do they block the airway? Could their acid erosion be caused by GERD…could this be related to chronic apneic events? We know many patients have dry mouth from medications, but have you thought about dry mouth being the effect of snoring? Sleep bruxism and xerostomia are not always related to OSA. However, xerostomia is common among people who have OSA because they often breathe through their mouth during the night. Sleep Bruxism, which takes place during an arousal episode, is believed to be the body’s natural defense mechanism to maintain a patent airway. Add a Mallampati score to your exam; the higher the number, the more you are at risk for OSA.
So now you have a patient who screens high risk…what do you do? Approximately, 80% of OSA in the American population goes undiagnosed. Sleep Apnea is diagnosed by Polysomnography, an overnight sleep study where your breathing and oxygen saturation is monitored. Only a physician can make this diagnosis. There are several treatment options to help manage a sleep breathing disorder. Lifestyle changes such as losing weight, or sleeping on the side instead of a supine position can be an option. Continuous positive airway pressure (CPAP) is a device which uses pressure of air to open the airway while sleeping. Surgical procedures can be helpful in some instances. A non-invasive way to manage sleep apnea is with a mandibular repositioning device (MRD). MRDs are simple mouth guard-like oral devices that are used to protrude the mandible while sleeping to open the airway. Qualified dental team members can educate patients about sleep apnea and guide them through a proven effective therapy with oral devices.
The American Sleep and Breathing Academy (ASBA) offers educational conferences and certification for dentists and hygienists to become qualified providers of oral device therapy.
Dental hygienists are an integral part of the healthcare team and play a role in identifying risk factors associated with OSA. By implementing a simple questionnaire and observing beyond the oral cavity, we can easily screen and then refer the patient to their primary care physician (PCP) for further testing for a sleep breathing disorder.
As sleep apnea becomes more prevalent, I would encourage the entire dental team, especially dental hygienists, to continue to learn more about symptoms, effects and treatment. You may just save a life.
Gina Pepitone-Mattiello RDH
Gina is a Registered Dental Hygienist (RDH) practicing with Long Island Dental Sleep Medicine. On a daily basis, she works with patients, identifying risk factors, signs, symptoms and managing obstructive sleep apnea through the use of oral appliance therapy (OAT). A pioneer in the dental sleep medicine field, Gina has developed an online on-demand certification course, "Certificate in Dental Sleep Medicine for the Registered Dental Hygienist", that is accredited by the Academy of Clinical Sleep Disorders Disciplines. This is the first and only certification course of its kind available to RDHs. In addition to treating patients and educating other hygienists, Gina lectures internationally about Obstructive Sleep Apnea and Oral Appliance Therapy, helping to advance the knowledge of dental sleep care professionals.