You’re the Only Chance I Have!

I had barely walked in the door and introduced myself when Bob, a very bright engineer, started to talk. “I know you’re not supposed to be able to help me,” he blurted out, “because everything I read says that oral appliances shouldn’t work for me, but you’re the only chance I have!”
Bob was obviously nervous. He spoke rapidly, without taking a breath. I knew he had just spoken several sentences, but they ran together without a pause. Interviewing is an art. To obtain the valuable information you need to help, some patients need to be coaxed or cajoled into sharing information that could have previously fallen on deaf ears. This was certainly not the case with Bob!

INITIAL PATIENT INTERVIEW: THE ART OF LISTENING

Bob had a very severe case of atrial fibrillation (a-fib). His condition had progressed to the point that the preventative medication that had been prescribed for him had now reached its dosage limits. In spite of the high level of preventative medication, he was having more and more severe episodes. He told of times when he was on very important business trips and an episode of a-fib would confine him to his hotel bed for 48 hours. His heart would beat over 200 times a minute for 24 hours, and it would take another 24 hours for him to recover. “It is very exhausting, and very detrimental to my career,” he stated, his voice riddled with frustration.
Bob paused and looked at me. There was a moment (maybe longer) of silence. He smiled, and then continued. I almost had the feeling that he had read How Doctors Think, by Dr. Jerome Groopman, in which the author poses the question, “The doctor is in, but is he listening?” Dr. Groopman describes the initial interview in which a patient is asked the first question and reports that his research has revealed that the average time a patient is allowed to speak before being interrupted is only 18 seconds.1 I found no reason to interrupt Bob because he was doing a great job of letting me know what he was experiencing with his health problems.
Bob is an engineer for, and a consultant to, Air Products. He is involved in process safety—engineering principles that apply to industrial accidents. His work does not involve slips, trips, and falls; it involves major explosions and chemical accidents. Following the World Trade Center attack, Bob also helped in the development of thermobarric weapons that were used to kill the enemies in their caves (in Afghanistan) without destroying any potential intelligence evidence. Such work demands complete concentration and accuracy, and now, because of Bob’s health problems, his career was at risk.
Bob was given a few options for the treatment of his medical condition by his cardiologist. The procedure recommended to him was an ablation procedure. This surgical technique does not predictably treat a-fib and the following complications are also possible: cardiac bleeding, the need for pacemaker placement, and a slight risk of death.2 While waiting for the ablation appointment, Bob had another serious a-fib episode and found himself in the hospital emergency room being evaluated by yet another cardiologist. It was this physician who asked Bob if he ever had a sleep study. The doctor referred to the recent New England Journal of Medicine articles associating sleep apnea with myocardial infarctions, stroke, diabetes, and atrial fibrillation.3,4 Bob replied that he had not ever had a sleep evaluation, so the study was scheduled.

POLYSOMNOGRAMS

We began to review the report of his “split night polysomnogram.” This means that halfway (or so) into the night the technicians had determined that the sleep disordered breathing was severe enough to proceed with a continuous positive airway pressure (CPAP) treatment trial and titration. The diagnostic portion lasted 4 hours, and Bob’s sleep efficiency was only 38%. Sometimes that can be attributed to the “first night affect,”5 but in Bob’s case it was most likely due to his severe obstructive disorder. Bob was diagnosed with severe obstructive sleep apnea with associated snoring, sleep fragmentation, and periodic leg movements. Continuous positive airway pressure (CPAP) was prescribed to treat his sleep disorder.

COPING WITH A CPAP DEVICE: ONE PATIENT’S EXPERIENCE

All Bob wanted to talk about next was his CPAP (device) experience. “l’ll bet you never wore one of THOSE! It was like trying to go to bed with my head out the car window while traveling 90 miles an hour! I tried. Boy, did I try!”
At the sleep laboratory, Bob kept the CPAP unit on for just under 2 hours. With only 8 cm of water pressure, Bob’s hypopneas stopped and he actually entered slow-wave sleep. He was not asleep long enough to get into REM (rapid eye movement) sleep, but it seemed clear that CPAP therapy could be the answer for Bob—and the 8 cm of water really was not that much pressure! These 2 positive indicators seemed to have convinced Bob to try to tolerate this treatment method.
Bob was given a CPAP unit, but he noted that when he tried to use it, he would have large amounts of fluid on his face and his pillow when he woke up. Bob immediately returned to Will’s Eye Hospital (Philadelphia) where he had previously undergone lacrimal duct surgery. It was explained that the “check valve” was not functioning properly in his lacrimal duct. As a result, he essentially had a direct connection from his nasal cavity to his eye. His eye surgeon made it very clear to him that CPAP was not an option for him.
Bob then returned to his sleep doctor. Bob told me, “My sleep doctor has a contemptuous attitude for anything other than the CPAP (or related devices), and seemed to actually have a contemptuous attitude towards me! He acted as though I wasn’t willing to try the CPAP, but with my eye…the fluids…to make it more graphic…when I blow my nose, I spatter the inside of my glasses. I just couldn’t do it! He didn’t even offer an oral appliance as an option.”
Without commenting, I checked the chart and saw that Bob listed a coworker, who was a patient of record in our office, as his referral source to our practice. The coworker, Vince, was a patient with severe sleep apnea who had an Respiratory Disturbance Index (RDI) that was reduced from 58 events to 2 events per hour by wearing an oral appliance. The RDI events include apneas (events where the patient stops breathing for 10 seconds or longer), hypopneas (events where the obstruction causes a decrease of at least 3% of peripheral oxygen levels), as well as other respiratory-related events. Clearly, Vince had talked to Bob.
“I’ve done the research,” said Bob. “I know that it is generally accepted that the oral appliance is not the first choice for severe sleep apnea, but don’t tell me that it will not be able to help severe cases like mine. So, can we give it a try? As I said, you’re my last hope.”


Figure 1. A joint vibration analysis of a patient without vibration episodes and joints functioning within normal limits.

Figure 2. This readout shows the results of a computerized jaw tracking, demonstrating a normal range of motion with the potential protrusion of 9.6 mm.

IS ORAL APPLIANCE THERAPY INDICATED?

Our initial oral exam quickly revealed that Bob could be fitted for an oral appliance. Bob wanted to know how this proposed appliance worked. And I didn’t hesitate to give him the explanation.
The airway will normally tend to collapse when we sleep because of a decrease in muscle tone. The CPAP device works by creating an internal splint of the airway keeping it open. Keeping the jaw forward at night also tends to put tension on the tensor veli pallatini, thereby creating tension in the soft palate. This counteracts the relaxation of the genioglossus muscle, keeping the tongue from pushing and sealing against the soft palate, thus keeping the airway open.6
“But just like any therapy, there are some potential complications,” I told Bob. “When we use an oral appliance, we ask our jaw muscles and our joints to be compromised during the night to support the airway. We need to do some studies on your jaw muscles and temporomandibular joints before we consider an oral appliance.”
The examination continued. We used joint vibration analysis (BioRESEARCH) to determine that his joints were indeed functioning within normal limits, and that he was without internal derangements, or degenerative joint disease (Figure 1). In addition, computerized jaw tracking recorded his range of motion, and our clinical examination revealed no contraindications to oral appliance therapy (Figure 2). The potential side effects of joint strain, muscle strain, and possible occlusal changes were reviewed. It was clear that Bob was eager to begin therapy since there was much to be gained by successful therapy. Together we decided to proceed with therapy, and it was now in our hands to manage any dental or craniomandibular complications. Upper and lower impressions, and a bite registration using a George Gauge, were then taken (Figures 3a and 3b).

Figure 3a, 3b, 3c. The George Gauge (Great Lakes Ortho) is a valuable instrument for taking a proper bite registration for oral appliance therapy. 3a. The George Gauge is being used to help determine and record the initial degree of protrusion the dental appliance will provide. 3b. That degree of protrusion and the maxilla/mandibular relationship can be easily recorded with quick setting bite registration paste on a removable bite fork. 3c. The gauge will help determine the amount of potential protrusion, as well as the mark the amount of protrusion chosen for the initial anterior positioning of the mandible.

The needed materials and records were sent with the prescription to the dental laboratory for the fabrication of the oral appliance.


Figure 4. This appliance (SomoDENT [SomnoMED]) is an excellent example of the type of a titratable, durable, mandibular advancement splint that can be used in the treatment of diagnosed sleep apnea when indicated.

Figure 5. This is an example of the SomnoDENT using an anterior midpoint stop.

Figure 6. The Thorton Adjustable Positioner (TAP), is another excellent appliance used in Dental Sleep Medicine. This is an example of the TAP III.

ORAL APPLIANCE DELIVERY

Bob’s appliance was inserted 3 weeks later (Figures 4 to 6). Titration and home care instructions were given, and a follow-up appointment in 3 weeks was arranged. Bob showed up for his 3-week appointment and reported that he had responded quickly to the oral appliance therapy. His wife reported that he stopped snoring and kicking his legs. He was now waking up feeling refreshed, and was aware that he was at last getting a full night’s sleep. What was even more amazing is that Bob reported he had no episodes of atrial fibrillation. This was the first time in his recent history that he went this long without the evidence of an event. Bob had no difficulty getting used to the oral appliance, in fact, he had far less difficulty than most. He also showed no signs of joint or muscle discomfort or pain.
Bob was referred back to his physician for retesting, but based on his previous negative experiences with him he refused to go. We tried to explain to Bob the importance of follow-up testing, and how it was possible despite the fact that he was indeed feeling better, not snoring, and not having a-fib attacks, that he was still having some degree of obstructions that could be further improved with titration of the appliance. Bob wanted no part of a follow-up study at this time and not only refused to go back to his original physician, he refused the alternative of a home study or a referral to a new sleep physician. At the recall visit, one year later, the appliance was checked and it was continuing to function very well for Bob. He had no dental changes and no reported joint/muscle pain or signs of dysfunction. Shortly after that visit, we received an emergency phone call from the Lehigh Valley Hospital. Bob had been admitted as an inpatient via the ER with a serious a-fib event. Bob’s appliance had broken the day before. (He had planned to call the office the next day.) Bob experienced this particular a-fib episode the very first night he had spent without the appliance.
Bob now accepted our referral to a new sleep physician. Recently, Bob had a follow-up polysomnogram. Interestingly, Bob still had an apnea hypopnea index (AHI) above normal, but significantly less than the original AHI of 76. As a result, we began titrating the appliance and monitored the success of the titration with ambulatory studies. Bob’s ADHI was determined to now be 2.1, well within the range of normal. Bob continues to do well and has had no further a-fib events. He rejoices that his quality of life has improved dramatically. Bob’s study has been sent back to his sleep physician, Dr. Schellenberg, who will meet with him and determine if a follow-up study with a full poly-somnogram should be done.

Figure 7. Sleep disturbed breathing in the form of obstructive disorders are a continuum. It is essential that snoring not be treated until a complete diagnosis is made.
Figure 8. These questions should be asked during patients’ medical update at their dental recall visit. Positive responses are predictive for obstructive sleep disorders.

SLEEP APNEA: CHALLENGES FACING DENTISTRY

While Bob’s story is not necessarily a common one—not everyone responds as positively to oral appliance therapy so quickly—there are many points to be gleaned from the experience. First and foremost, dentistry has the potential to make a very useful solution available for patients with obstructive disorders when indicated.7-9 However, in order to be able to provide that service, the practice model that we have become comfortable with in dentistry must be examined and altered.
We must learn how to work, network, and communicate with our medical colleagues in a more meaningful way. We must understand that our therapy will have degrees of success, and it will not be as predictable as the care we normally give within the practice of general dentistry. We must learn interviewing techniques that may have not been required in our general dental settings. In addition, we must learn how to educate and motivate not only the public, but also our physicians who, in many cases, may have a bias against the use of a dental therapeutic approach with an oral appliance. Unfortunately, dental sleep medicine has the potential to create a competitive environment between us and our medical colleagues. We need to work together to eliminate any reality or perceptions of interprofessional competition, and to ensure that patients are given all the options available to them. This includes the oral therapeutic option which may be in their best interest.
We know that patients with obstructive disorders have significant potential to develop the comorbidities of stroke, myocardial infarctions, heart attacks, gastro-esophageal reflux disease (GERD), and diabetes. There is also a serious concern for the associated snoring and excessive daytime sleepiness that can lead to depression, marital conflicts, and motor vehicle and work-related accidents.
More than 90% of the disorder remains undiagnosed.10 Dentistry, in this author’s opinion, should be the no. 1 portal of patients into sleep medicine diagnosis and treatment. Very basic questions can lead to the suggestion of the potential of the disorder, and a proper referral (Figure 7). It is extremely important that dentists understand that obstructive disorders are a continuum that starts with snoring at one end, and has severe apnea on the other. It should also be noted that snoring should never be treated without a proper diagnosis (Figure 8).
The following is the current policy statement from the American Academy of Sleep Medicine: Oral appliances are indicated in patients with mild to moderate obstructive sleep apnea (OSA), who prefer their use to continuous positive airway pressure (CPAP) treatment; or who are inappropriate candidates for, or who are refractory to, CPAP treatment.11 It should be noted that this statement does NOT suggest that oral appliance therapy (OAT) should be the first choice of therapy in all cases. Nor does it suggest that OAT is in-appropriate for severe cases. Bob’s case, as described in this article, is a perfect example of this concept.
A look at the history of dentistry reveals that our profession has faced challenges many times in the past. Our profession is facing its greatest challenge—to truly step out of the “box of dentistry” and become physicians of the oral cavity. We have learned that our skills can be helpful, and at times required, in the diagnosis and treatment of our patient’s chronic pain, joint dysfunction, as well as headaches and migraines. Now, we need to add obstructive sleep disorders to the list.

CLOSING COMMENTS

Issues involving the quality of sleep become very important to the patient and the dentist. It is during sleep that the obstructive disorders exist. It is during sleep that patients tend to parafunction, creating the forces that threaten our patients and the dentistry that is done for them every day. We are faced with the challenge to understand sleep, our role in diagnosing and treating patients with obstructive disorders, as well as the parasomnia of bruxism. Accepting this challenge will indeed improve the lives of our patients!

Acknowledgment

The author would like to thank Dr. Don Malizia for his invaluable research efforts. 

References

  1. Groopman JE. How Doctors Think. Boston, MA: Houghton Mifflin; 2007:17.
  2. Spragg DD, Dalal D, Cheema A, et al. Complications of catheter ablation for atrial fibrillation: incidence and predictors. J Cardiovasc Electrophysiol. 2008;19:627-631.
  3. Lavie P, Lavie L, Herer P. All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age. Eur Respir J. 2005; 25:514-520.
  4. Yaggi HK, Concato J, Kernan WN, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353:2034-2041.
  5. Tamaki M, Nittono H, Hayashi M, et al. Examination of the first-night effect during the sleep-onset period. Sleep. 2005;28:195-202.
  6. Ferguson KA, Cartwright R, Rogers R, et al. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29:244-262.
  7. Schmidt-Nowara W, Lowe A, Wiegand L, et al. Oral appliances for the treatment of snoring and obstructive sleep apnea: a review. Sleep. 1995;18:501-510.
  8. Lowe AA, Sjoholm TT, Ryan CF, et al. Treatment, airway and compliance effects of a titratable oral appliance. Sleep. 2000;23(suppl 4):S172-S178.
  9. Tsuiki S, Ryan CF, Lowe AA, et al. Functional contribution of mandibular advancement to awake upper airway patency in obstructive sleep apnea. Sleep Breath. 2007;11:245-251.
  10. Baumel MJ, Maislin G, Pack AI. Population and occupational screening for obstructive sleep apnea: are we there yet? Am J Respir Crit Care Med. 1997;155:9-14.
  11. Kushida CA, Morgenthaler TI, Littner MR, et al; American Academy of Sleep. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. 2006;29:240-243.

Dr. Glassman maintains a private practice in Allentown, Pa, that is limited to chronic pain management, temporomandibular joint dysfunction, and dental sleep medicine. He is a Diplomate of the American Academy of Cranio-facial Pain, a Fellow of the International College of Craniomandibular Orthopedics, a Fellow of the Academy of Dentistry International, and a Diplomate of the American Academy of Pain Management. He is on staff at the Lehigh Valley Hospital where he serves as a resident instructor of craniofacial pain and dysfunction and dental sleep medicine. He is a Diplomate of the Academy of Dental Sleep Medicine, and is on staff at the Sacred Heart Hospital Sleep Disorder Center. He was recently named co-medical director of the St. Lukes Hospital Headache Center. He can be reached at (610) 435-6724 or rbglass@aol.com.

Disclosure: The author receives honorariums for speaking from BioRESEARCH and SomnoMED.



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