This is part two in a six-part series on the evolution of the sleep technologist role. AAST has engaged professionals from across allied healthcare to address, from their perspective, the value of collaborating more closely with sleep technologists and/or incorporating the discipline into their area of health.
Check out part one here.
As a clinical dentist, I have been intimately familiar with the issue of airway patency for almost 40 years. It was during my dental school days back in the late 1970's that I was introduced to the concept of "form follows function" as it pertains to facial growth in children and adolescents.
The concept, in a nutshell, is that human infants are obligate nasal breathers. During nasal breathing, the lips form a seal and the tongue rests upwards and forward against the hard palate. This tongue position provides key growth forces inducing the upper jaw to widen, limiting its vertical growth, thereby promoting the lower jaw to grow in a more horizontal as opposed to vertical direction. All this activity leads to a more balanced facial complex and a more patent upper airway.
For me, the need for a patent airway in the context of orthodontics and facial growth was second nature. It was almost 20 years later that I was re-introduced to airway patency but in a completely different context from facial growth . . . the arena of Sleep Disordered Breathing (SDB).
After a patient is diagnosed with Obstructive Sleep Apnea (OSA) by a physician trained in sleep medicine, the dentist may be called upon to be part of an interdisciplinary team to treat the patient. The dentist possesses a unique skillset based on their familiarity with the craniofacial complex and this is an important requirement in assuring the health of the teeth, muscles, and joints during treatment.
The American Academy of Dental Sleep Medicine (AADSM) recommends that, ". . . sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea), and that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy."
Dentistry can be involved in the treatment of SDB in several ways. Probably the most recognizable is Oral Appliance Therapy (OAT). In OAT, a dentist, with training in dental sleep medicine, constructs an oral appliance to open the airway by some method, the most common being either advancing the mandible, protruding the tongue, or utilizing some combination of both. In the last decade, there have been considerable advances in oral appliance design and as a result the dental team may be able to provide a comfortable and effective alternative option for select OSA patients.
There has been substantial research performed with OAT and there is going to be even more research performed in the future regarding the effectiveness of OAT vs. CPAP. With continued communication between all the members of the sleep team (the sleep physician, dentist, and sleep technologists) we hope to see continued advancements in the field of SDB treatment.
Other dental treatment modalities include orthodontics, which provides a more interceptive approach, and Maxillary and Mandibular Advancement (MMA) performed by an Oral Maxillofacial Surgeon. MMA and other oral surgery procedures may be an option when more conservative treatments prove unsuccessful.
In the modern era of dentistry, our focus has always been on prevention. Concerning the prevention of problems with facial growth, we try to encourage parents to consider early interceptive orthodontic intervention. It has become quite common to treat children in two distinct phases. A first, or early interceptive phase, utilizes orthopedic treatment in the young child to improve transverse, anterior-posterior, and vertical skeletal deformities. Increasing the width of a transversely deficient palate, with treatment known as rapid palatal expansion, will not only create additional room for the future dentition, but will also have sleep related benefits. The roof of the mouth is also the floor of the nasal cavity . . . enlarging one will enlarge the other. Expanding the palate makes more room for the tongue and makes more room in the nasal cavity. This enhances the possibility for increased upper airway patency.
Because airway patency is a critical to facial growth, early identification of airway obstruction and treatment, orthodontically and in tandem with an otolaryngologist, is critical to long term success. This same screening protocol we utilize to identify facial growth concerns, places the dental team in a unique position to evaluate a large segment of the child population for SDB.
Biannual visits, coupled with a lengthy examination period and direct communication between the dental hygienist and the parent, allows for the ideal situation to address issues concerning sleep disordered breathing and behavioral, cognitive, social, psychological, etc. issues.
The dental team may be able to stimulate parents to seek further consultation. Pediatric SDB is becoming more recognized and the result may be more involvement in early diagnosis and treatment, with a subsequent increase of in-lab sleep testing involving children and adolescents.
Going forward, as the field sleep medicine advances, we may find that sleep physicians, sleep dentists and sleep technologists, along with a growing number of other medical disciplines, may be more interconnected than we first realized. Let's work together and enjoy the ride.