My wife said I snore, but I never hear it. My kids hate to share a hotel room with me because they say I snore, but again, I never hear it. I fall asleep quickly at night, but wake up all night long. Sometimes I wake up in the morning with a headache. I’m tired throughout the day and usually take a nap at lunch. If we are going to drive somewhere for more than an hour, I let my wife drive so I can sleep the whole way. I took a course on sleep apnea as part of my continuing education and it felt like a Sunday morning sermon with the preacher pointing his finger directly at me! Do I have a problem?
My son, Dr. Phillip Kraver and I began to look into sleep apnea more and learned about the diagnosis and treatment of obstructive sleep apnea. I already had been making anti-snoring devices for many years in our office, but this was controversial because I didn’t know if the patients actually had obstructive sleep apnea (OSA) or not. I would give them the sleepiness test that was supplied by Glidewell Dental Labs, and it never dawned on me that I should have taken it myself!
The Epworth Sleepiness Scale
In the patient’s typical daily life, how likely are they to doze off or fall asleep in the following situations (not just feeling tired)? Use the following scale to choose the most appropriate number for the situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
- Sitting and reading
- Watching Television
- Sitting, inactive, in a public place (theatre, meeting, etc.)
- As a passenger in a car for an hour without a break
- Lying down to rest in the afternoon when circumstances permit
- Sitting and talking to someone
- In a car, while stopped for a few minutes in traffic
- Sitting quietly after lunch without alcohol
- Driving a car or truck for two (2) hours or more
- Score of 1-6: you’re getting enough sleep
- Score of 4-8: you tend to be sleepy during the day; this is the average score
- Score of 9-15: you are very sleepy and should seek medical advice
- Score of 16 or greater: you are dangerously sleepy and should seek medical advice
- Snoring: Do you snore on most night (>3 times per week)? Yes=2, No=0 Is your snoring loud (heard through doors and walls)? Yes =2, No=0
- Sleep Noises: Has it ever been reported to you that you stop breathing or gasp in your sleep? Never=0, Occasionally=3, Frequently=5
- Collar size: What is your collar size? Male <17 inches=0, Male >17 inches=5; Females <16 inches=0, Females >16 inches=5
- Daytime Sleepiness: Do you occasionally fall asleep during the day when: Busy or active? No=0, Yes=2; Driving or stopped at a light? No=0, Yes=2
- Hypertension: Have you ever had or are you being treated for high blood pressure? No=0, Yes=1
- 5 or less has allow incidence for sleep related disorder
- 6-8 you need to speak with your physician
- Greater than 8 has a high probability for sleep related disorders and you should seek medic advice.
We attended a seminar by Dr. John Tucker on Obstructive Sleep Apnea (OSA) and at the meeting they had a vender who was trying to sell one of those expensive home sleep study instruments. It measured everything from PaO₂(blood oxygen levels), actigraphy (body movements), sleep positions, levels of sleep (wake, light sleep, deep sleep and REM), heart rate, snoring loudness in decibels to peripheral arterial tone which mirrored your autonomic nervous system. WOW! They let me wear one over night in the hotel and the results were sobering. I just thought I snored like everyone else, but instead the study suggested I had sleep apnea!
I showed up 8pm on a Friday night at Cape Coral Hospital’s ER to check in for my over night sleep study. My wife came along to take pictures, tuck me in and bring cookies for the technician(s). The room was nice, but the bed and pillows were uncomfortable. You would think that they would have the most comfortable bed in the world for you to sleep in, after all, they do want you to sleep. Before bed, you go into the set-up room where I was hooked up to an electroencephalogram, electrocardiogram, electromyogram, nasal cannula monitor, chest and abdominal breathing straps, leg activity monitor and a positional monitor. Wires, wires and more wires! And that tape under the nose to hold the nasal cannula in place was the worse! Needless to say I couldn’t sleep a wink. Every time I rolled over something was poking into me or coming undone. And going to the bathroom was such an ordeal it is a wonder anyone could sleep after that. I just hoped I didn’t have to repeat the test to get my results.
Standard of Care:
A Proposed Alternative Dental Appliance Oriented Treatment Plan for Obstructive Sleep Apnea: (not standard of care, yet)
For this hypothetical alternative treatment plan to work a close relationship between sleep medicine physicians and sleep therapy dentists needs to be established. This is how I think it should flow but it is just “my opinion, opinion, opinion” (Tuckerism). The biggest problem with this alternative more logical plan is that there are so few dentists in the field of sleep medicine due to the obstacles of file medical insurance and Medicare.
- Screening for OSA – The need for screening can be recognized by either the primary care physician or the dentist.
- Overnight screening at home with a pulse oximeter that records data. These are relatively cheap instruments readily available at department stores or over the internet. They don’t have to be as fancy or as expensive as the one I used at the show. Sleep dental office should have them on hand to screen their suspected OSA patients. Once the data is downloaded from the pulse oximeter and the numbers organized into a report, the case can be referred to a sleep physician.
- The data is analyzed by the sleep physician to see if a polysomnographic (sleep) study is warranted. Most over night testing facilities that do sleep studies cost a lot of money and can be cost prohibitive for many non-insured patients. Even with insurance, it can be more than $3000 out of pocket if you have a high deductible.
- Polysomnogram – Once the diagnosis of OSA is established, the patient is referred to the local dental sleep dentist for manufacturing of a dental sleep appliance.
- Dental sleep appliance – Having the dentist make a dental sleep appliance first just makes sense. Most of the people who will get a sleep appliance will benefit greatly from it. Those who need more than just an appliance can then be verified with a follow-up polysomnograph with the appliance in place. If CPAP is warranted, then with the appliance in the mouth to hold the chin in the proper position the CPAP is titrated to a pressure that opens the airway (at a much lower and tolerable CPAP pressure). This approach seems more logical and with a better outcome for the patient, but is not currently being practiced by a majority of sleep physicians around the world.
- CPAP – Big gun, if there is no resolution of the OSA with OAT.
1. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults Comparative Effectiveness Reviews, No. 32 Investigators: Ethan M Balk, MD, MPH, Denish Moorthy, MBBS, MS, Ndidiamaka O Obadan, MD, MS, Kamal Patel, MPH, MBA, Stanley Ip, MD, Mei Chung, PhD, MPH, Raveendhara R Bannuru, MD, Georgios D Kitsios, MD, PhD, Srila Sen, MA, Ramon C Iovin, PhD, James M Gaylor, BA, Carolyn D’Ambrosio, MD, MS, and Joseph Lau, MD. Tufts Evidence-based Practice Center Rockville (MD): Agency for Healthcare Research and Quality (US); July 2011. Report No.: 11-EHC052
2. Sleep Breath. 2012 Feb 26. [Epub ahead of print] The fairness of the Epworth Sleepiness Scale: two approaches to differential item functioning. Ulander M, Arestedt K, Svanborg E, Johansson P, Broström A. Institution of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden, firstname.lastname@example.org.
3. Cephalalgia. 2011 Dec 15. [Epub ahead of print] Sleep apnea headache in the general population. Kristiansen HA, Kværner KJ, Akre H, Overland B, Sandvik L, Russell MB. Head and Neck Research Group, Akershus University Hospital and Campus Akershus University Hospital, University of Oslo, Norway.
4. Sleep. 2008 Feb;31(2):249-55. The relationship of daytime hypoxemia and nocturnal hypoxia in obstructive sleep apnea syndrome. Fanfulla F, Grassi M, Taurino AE, D’Artavilla Lupo N, Trentin R. Pulmonary Division, Istituto Scientifico di Pavia, Italy. email@example.com
5. Sleep Breath. 2012 Feb 10. [Epub ahead of print] Energy expenditure in obstructive sleep apnea: validation of a multiple physiological sensor for determination of sleep and wake. O’Driscoll DM, Turton AR, Copland JM, Strauss BJ, Hamilton GS. Department of Respiratory and Sleep Medicine, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3168, Australia, firstname.lastname@example.org.
6. Sleep. 2011 Aug 1;34(8):1075-81. Quantitative effects of trunk and head position on the apnea hypopnea index in obstructivesleep apnea. van Kesteren ER, van Maanen JP, Hilgevoord AA, Laman DM, de Vries N. Department of Clinical Neurophysiology, Sleep Laboratory, St. Lucas Andreas Hospital, Amsterdam, The Netherlands. email@example.com
7. Sleep. 2011 Jan 1;34(1):73-81. The 2007 AASM recommendations for EEG electrode placement in polysomnography: impact on sleep and cortical arousal scoring. Ruehland WR, O’Donoghue FJ, Pierce RJ, Thornton AT, Singh P, Copland JM, Stevens B, Rochford PD. Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia. Warren.Ruehland@austin.org.au
8. Sleep Med. 2012 Jan;13(1):21-8. Epub 2011 Nov 21. Heart rate increment in the diagnosis of obstructive sleep apnoea in an older population. Sforza E, Chouchou F, Pichot V, Barthélémy JC, Roche F. Service de Physiologie Clinique et de l’Exercice, CHU Nord, Saint-Etienne, Faculté de Médecine Jacques Lisfranc, PRES Université de Lyon 42023, Université Jean Monnet, Saint-Etienne, France. firstname.lastname@example.org
9. Ann Biomed Eng. 2009 Sep;37(9):1807-17. Epub 2009 Jun 24. Role of upper airway dimensions in snore production: acoustical and perceptual findings. Ng AK, Koh TS, Baey E, Puvanendran K. School of Electrical and Electronic Engineering, Nanyang Technological University, Singapore, 639798, Republic of Singapore. email@example.com
10 . J Clin Sleep Med. 2011 Jun 15;7(3):301-6. Sleep staging based on autonomic signals: a multi-center validation study. Hedner J, White DP, Malhotra A, Herscovici S, Pittman SD, Zou D, Grote L, Pillar G. Sleep Laboratory, Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
11. Drugs. 2009;69 Suppl 2:77-91. doi: 10.2165/11532000-000000000-00000. Can improving sleep influence sleep-disordered breathing? Sériès F; Workshop Participants. Collaborators (12) Centre de Pneumologie Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada. Frederic.firstname.lastname@example.org
12. Angiology. 2012 Jan 20. [Epub ahead of print] Size and Subclasses of Low-Density Lipoproteins in Patients With Obstructive Sleep Apnea. Sopkova Z, Berneis K, Rizzo M, Spinas GA, Dorkova Z, Tisko R, Tkacova R. Department of Respiratory Medicine and Tuberculosis, Faculty of Medicine, P.J. Safarik University and L. Pasteur University Hospital, Kosice, Slovakia.
13. Int J Pediatr Otorhinolaryngol. 2011 Mar 3. [Epub ahead of print] Obstructive hypopnea and gastroesophageal reflux as factors associated with residual obstructive sleep apnea syndrome. Wasilewska J, Kaczmarski M, Debkowska K. Department of Paediatrics, Gastroenterology and Allergology, Medical University of Bialystok, Waszyngtona Street 17, 15-274 Bialystok, Poland.
14. Conf Proc IEEE Eng Med Biol Soc. 2011 Aug;2011:3209-12. Concurrent variations of cerebral blood flow and arterial blood pressure in simulated sleep apnea. Alex R, Bhave G, Al-Abed MA, Bashaboyina A, Iyer S, Watenpaugh DE, Zhang R, Behbehani K.
15. Diabetes Technol Ther. 2011 Sep;13(9):945-9. Epub 2011 Jun 29. Effects of sleep apnea severity on glycemic control in patients with type 2 diabetes prior to continuous positive airway pressure treatment. Pillai A, Warren G, Gunathilake W, Idris I. Sherwood Forest Hospitals Foundation Trust, Sutton in Ashfield, United Kingdom.
17. Braz J Otorhinolaryngol. 2011 Jul-Aug;77(4):516-21. Anthropometric data as predictors of Obstructive Sleep Apnea Severity. [Article in English, Portuguese] Pinto JA, Godoy LB, Marquis VW, Sonego TB, Leal Cde F, Artico MS. Hospital e Maternidade São Camilo, São Camilo Hospital and Maternity, Pompéia Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo, São Paulo. email@example.com
18. Sleep. 2004 Sep 15;27(6):1171-9. Comparison of limited monitoring using a nasal-cannula flow signal to full polysomnography in sleep-disordered breathing. Ayappa I, Norman RG, Suryadevara M, Rapoport DM. NYU School of Medicine, New York 10016, USA.