TREATMENT OF SLEEP APNEA

A patient shows up for consultation complaining of a snoring problem. Although he mentions not to suffer from this condition, his wife asked him to sleep in a separate room and fishing buddies say they are quite annoyed by the snoring noise. He wants to get a dental orthotic for snoring and asks for your opinion. He does not suffer from high blood pressure and fatigue, factors that might suggest a sleep apnea problem.

Can he go to the dentist?

Although the patient seems in perfect health, the procedure is to send him to a sleep specialist for evaluation. Very often, this brief evaluation will give a negative diagnosis, but it is not uncommon that the patient suffers from sleep apnea, in which case the treatment may be different. An ENT evaluation would also be desirable, especially if the patient has significant anomalies in the throat tissues or a nasal obstruction. In some cases, intervention may be practiced. Moreover, recommendations of the Canadian Thoracic Society are clear to the effect that it is in the patient’s interest to be evaluated by a physician before obtaining an intra-oral dental device. Thus, a dentist who sees a patient in consultation for snoring should first be referred to a physician for evaluation before producing such a device. In cases where the patient is just a snorer, he could be sent to the dentist for an orthotic against snoring. The latter will explain what the treatment is, and the probable number of visits. If the patient is interested, models of his teeth are made and an orthotic is produced. During the next appointment, the orthotic is set in the mouth and the patient is given a timetable for the gradual advancement of the splint (and the mandible). The more the mandible is pushed forward by the device, the better the chances of resolving the snoring problem. However, a very gradual progress is recommended since a movement done too quickly could cause pain in the jaw.

A patient walks into your office and tells you that he has been diagnosed with obstructive sleep apnea. He’s been using a compressor for some time now and is dissatisfied. Also, he’s tired because he doesn’t use it much. He thinks that the side effects associated with wearing a mask prevents his sleep to the point where he’s even more tired with the compressor than without. He has heard of dental orthotics and asks your advice.

SHOULD WE SEND HIM DIRECTLY TO THE DENTIST?

We must first ask the patient if he has contacted the doctor who prescribed the compressor, or the private company that sold him the compressor. Sometimes a simple adjustment or a revision of the compressor operation instructions will allow the patient to fully benefit from using the device. However, if the patient contacted the physician or met with the representative of the nCPAP company and they cannot help, it is quite appropriate to go to a dentist who makes mandibular advancement splints. All dentists can offer this service, but given the relatively small number of orthotics made, only a few dentists have a sufficient volume of patients referred by physicians to be interested in acquiring expertise in the field. Initially, the treatment of an apneic patient is much like that of the snorer. Made similarly for the latter, the device is designed to advance the mandible to clear the airway. It can often be the same device used by the dentist. Monitoring an apneic patient is often longer and more complex than monitoring a snorer. It is not uncommon for the apneic patient to stop snoring at the first control appointment, but that he still suffers from apnea. The orthotic is then gradually advanced until the patient feels much better or that he has reached maximum tolerable advancement. A monitoring oximetry can then be made to determine if the patient has decreased the number of apnea episodes to an acceptable level. In the case where the oximetry test is not acceptable, one should continue the advancement of the orthotic as far as possible. If the test appears successful, it is time to return the patient to a sleep specialist for a reassessment. Experience gained by the author during research at the Quebec University Institute of Cardiology and Pneumology determined that if oximetry is a valuable technique for the evaluation of the patient’s condition, a physician competent in the field must analyze it, because the results can be quite different from what would be obtained using a more accurate assessment technique. Once adjustments are completed, the dentist should see the patient for annual follow-ups. Most dental devices have a three to five year lifespan: this period can vary between individuals.