by Bruce B. Baird, DDS
One of the hottest trends in dentistry today is the treatment of sleep disorders, sleep-disordered breathing, or more specifically, obstructive sleep apnea (OSA). I treat sleep disorders, and like many dentists, I am also a patient. Like most adults with OSA, my symptoms began in childhood but were undetected until I was 49 years old.
Discovering my sleep apnea
I began my journey in the treatment of sleep apnea totally by chance in 2005 when I met Dr. Chris Hansen and Dr. Dan Tache. They invited me to attend a seminar about sleep disorders given by the late Dr. Edward P. Spiegel. I had always been proud of my knowledge about a broad spectrum of topics in dentistry, but as I was sitting in that seminar, I felt as though I were listening to a foreign language: "Apnea hypopnea index (AHI)," "respiratory distress index (RDI)," "obstructive sleep apnea (OSA)," "mandibular advancement device (MAD)" ... I thought, "What the heck are they talking about?"
After the course, I realized how little I knew about sleep apnea and nothing about how it had been affecting my life since I was a small child. I invited Dr. Spiegel to come to my office to do a private seminar. We scheduled a couple of patients to evaluate for sleep apnea. We had scheduled to do an overnight home sleep study on both patients to learn how to treat them. It was my luck that one of our patients didn't show up. I knew I snored often, so I volunteered to take one for the team and be a patient for the study.
Our first patient had been diagnosed with sleep apnea previously, but he could not use his continuous positive airway pressure (CPAP) machine - a common issue among patients with this condition. We looked at my results and found that I had severe sleep apnea! I stopped breathing 33 times per hour, my pulse would rise to 178 beats per minute, and my pulse oximetry would drop to 63%. I basically stressed my system all night long. Obstructive sleep apnea, a name that had so recently seemed foreign to me, had become my reality.
A physician's path of treatment
Let's go back seven years earlier. I was diagnosed at the age of 42 with idiopathic cardiomyopathy. I was given beta-blockers, ACE inhibitors, and blood pressure medications. My left ventricular ejection fraction was in the low 30s when it should have been in the 70s for a healthy male of my age. Unfortunately, I was overweight and tired all the time with intermittent episodes of anxiety and depression.
Little did I know, all of these conditions could be related to sleep apnea. I got serious about losing weight, and that seemed to help most of my symptoms. Loss of weight can help the severity of sleep apnea. Hmmm?
The true cause of my sleep apnea
Let's go back many years earlier to a time when I was about 10 years old. Back in the 1960s, it was a common procedure to have your tonsils removed at an early age. I didn't think I needed mine removed, although I had severe allergies, was always sniffling, and had trouble breathing and sleeping. I was tired all the time, and I had quite a bit of trouble paying attention. Today, that's called attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD).
When I was growing up, the treatment for that was a knock on the head, as if to say, "Pay attention!" The treatment today is a stimulant, such as Ritalin. Remember, more and more kids these days are not having their tonsils removed because insurance companies won't pay until a certain number of strep tests have had positive results. These children need their tonsils and adenoids removed and can benefit greatly from interceptive orthodontics and expansion, as well as from allergy testing and treatment.
My journey to treatment
When I was first diagnosed with sleep apnea, I decided that I needed to wear an oral appliance for the treatment. I also decided that, if I was going to be treating OSA in my office, I needed to wear multiple appliances to find out which was most comfortable for me. Doing so would enable me to speak to my patients from experience, which I have always found to be the best.
I wore a TAP 1 and a TAP 2 appliance, a SomnoDent, a NORAD, and several others. The most comfortable for me was either a TAP or the SomnoDent. They helped my OSA by about 50%, lowering my respiratory distress index to 17. Oral appliance therapy is generally recommended for those with an RDI under 20, which is considered mild to moderate. Remember that mine was 33, which is considered severe, when my sleep apnea was first diagnosed.
I didn't really want to wear a CPAP. The oral appliance helped, but when I began to experience a change in my bite and temporomandibular issues, I decided to go for surgery. These bite issues occur in very few of my patients, but unfortunately, they did occur for me.
I decided to undergo several surgical procedures to "cure" my sleep apnea once and for all. A friend of mine, who is an excellent surgeon, decided to do a genioglossus advancement (GA), also known as a genial tubercle advancement (GTA). A GA or GTA is a surgical procedure during which the base of the tongue is pulled forward, usually to increase the size of an airway that is too small due to either a deformity or a sleep disorder. He also did a nasal septoplasty and a palatal resection, and he removed my tonsils. He recommended a couple of different appointments for surgery, but I told him, "You only get one shot at this."
After a six-and-a-half-hour surgery, it took me six weeks to recover. My ability to breathe through my nose was improved, and I seemed to have a more open airway. I asked my wife how my snoring was, and she told me that it was better but not totally gone. I lost 40 pounds after the surgery, which helped immensely with my symptoms. When retested, however, I still had sleep apnea.
Impact
At that point, I couldn't wear an oral appliance, and I had had surgery that did not work. I insisted to my wife that I wasn't going to wear a CPAP. Then, about a year after I made that announcement, I was driving home from visiting my dad when I fell asleep and drove off the road. It was around 10 a.m. I was not hurt, and fortunately, no one else was hurt either. That was it!
At the time, I owned 10% interest in our local sleep lab. I called and said that I wanted a CPAP that day. I have been wearing one for the last five years. I sleep better, my weight is under control, my ejection fraction is in the mid-40s, and I work out every other day.
Why am I telling you this story? I'm telling you because I know that dentists are best suited to diagnose sleep apnea. We see our patients twice a year. Oral appliance therapy is successful for the right cases. Surgery is indicated in certain cases, and CPAP therapy remains the gold standard for treatment in severe cases. I help my patients regardless of whether I am doing oral appliance therapy or recommending CPAP therapy. I recommend surgery for those patients who have problems with high upper airway resistance - usually septoplasty and tonsil removal. I don't recommend burning anything away or palate resection, and I wouldn't have the genial tubercle advancement done again (just my personal opinion).
What you can do
Patients who have breathing disorders share many common symptoms. Statistically, male patients with 17.5-inch necks who snore or female patients with 16.5-inch necks who snore have a 95% chance of having obstructive sleep apnea.
Most physicians simply treat OSA by giving a pill for each of the symptoms but rarely diagnose the problem. There are better ways, however, and that's why we should take more active roles in helping our patients live full and complete lives. The following are some of the symptoms of sleep apnea:
- High blood pressure
- Lack of energy
- Morning headaches
- Excessive weight gain and obesity
- Gastroesophageal reflux
- Sexual dysfunction
- Depression
- Frequent nocturnal urination
- Poor mental acuity and memory loss
- Increased risk of stroke, heart attack, and diabetes
- Bruxism
When I see acidic erosion and bruxism together, I immediately think of OSA. In the past, I would have treated these patients with a bruxism or snoring appliance, such as a Silent Nite or Snore Guard. Today, I have patients do an at-home sleep study before choosing the appropriate appliance. Treating the symptom of snoring without further testing can cause a condition known as "silent apnea" because the patient quits snoring but continues to stop breathing. If you prescribe a bruxism guard to a patient without first testing him/her for OSA, his/her condition can worsen by as much as 50%. The lesson to learn here is that we need to be well-versed in what is called sleep-disordered breathing, which affects our patients and our dentistry in many, many ways.
My goal in writing this article is to make you think. There are numerous courses from which you can learn about treating sleep apnea. A list of mentors and resources can be found on productivedentist.com/OSAresources.
Bruce B. Baird, DDS, is a well-respected cosmetic and reconstructive dentist in Granbury, Texas. He is a cofounder of Productive Dentist Academy, the founder of Comprehensive Finance, an honored fellow of the American Academy of Implant Dentistry, and a diplomate of the International Congress of Oral Implantology. He has been lecturing internationally for more than 25 years on all aspects of patient care and communication.
