Hi everyone, I'm Dr. Jeff Horowitz, and I'm here to speak with you today about screening for sleep-related breathing disorders. So today I have the pleasure of presenting with Dr. Christopher Hart. He's a fellow diplomat with the American Academy of Sleep Medicine and the American Board of Dental Sleep Medicine, as am I. And together, the two of us want to give you the why as to why you should be screening for sleep-related breathing disorders and how you should be doing it. So we're going to try to keep this as simple as possible and try to make a really compelling argument as to why every single dentist out there should be doing this. So this is my information. I'm not going to spend a lot of time here, other than to say, please feel free to contact me at the email address that you see at the bottom of the screen. That was my first office in Conway, South Carolina, which still exists about a half a mile from where I'm speaking to you from right now. And that is where all of my sleep journey started. So please email me if you have any questions at jhorowitzdmd at gmail, or you can visit me on my Facebook group, Dentists in the Know, where we have open, honest conversation about the things that are going on in dentistry. So let's talk about what the objectives are for this part of the lecture, for part one. First I'm going to tell you why all dentists need to be screening and identifying sleep-related breathing disorders. And then second, I want everyone out there to understand what I call the crisis of the undiagnosed. Because you see, there aren't many conditions out there or many diseases out there at this point that pose such a threat to the overall health of people from every continent and every ethnic background. So we're going to talk about the crisis of the undiagnosed today. We're going to talk about the limitations of the current medical model and why so many patients are either not diagnosed or misdiagnosed when it comes to sleep-related breathing disorders. We're going to talk about collaborating with the medical community, not just for the patient, but also to the benefit of the dental practice. And then finally, we're going to explain the etiology, the prevalence, we're going to talk about the risks and the comorbidities of sleep-related breathing disorders. So let's get off to the races here. So I've never done a lecture where I did not pay homage to one of my great mentors, Dr. John Koist, who taught me everything there is to know about risk management in dentistry. It completely changed the way I think about everything that I do. So now when I look at a patient, all I'm thinking is, how do I manage this patient's risk? How do I manage their risk for caries? How do I manage their risk for periodontal disease? How do I manage their medical risks, their functional risks? Let's go back to those medical risks, because if I can have an impact on their medical health, on their overall health, then I now go from being a tooth doctor to an oral medicine practitioner. And that's really the place that I like to be. I like to be a health care advocate for my patients. And I think when you do that, you become a different type of practice. So the typical diagnosis here, and what most dentists would say, is that we've got a broke tooth. In South Carolina, we don't always have the best grammar. I can say that because I've lived here for 30 years now. This would be a broke tooth. But it doesn't matter what it is as much as it matters why it happened. Because if I can explain to the patient that this tooth really shouldn't have been restored with a big fat post and a pin, that there wasn't enough supporting tooth structure, I might have been more compelling and been able to tell them, I can reduce your risk for a future emergency by placing an implant versus going through all the time and expense of a root canal, a post, a crown, and then have it eventually break. So I want to talk to you a little bit about how obstructive sleep apnea and sleep-related breathing disorders can affect outcomes for other areas of dentistry. Because I really believe that most dentists don't understand how much this condition can impact everything else you're doing in dentistry. So some of the general dental practice outcomes that are affected by sleep apnea are diagnosis and treatment planning, restorative, prosthetics, perio, implants, oral surgery, and sedation. Boy, did I leave anything out there? I don't think I did. My point is that this affects almost everything that you're doing in general practice, which is why every dentist needs to be made aware of this condition and at least how to identify these patients. So for an example, I would ask most dentists in a lecture what they would do if they saw that case. If I walk around the room, 9 out of 10 dentists are going to say, oh, look at those abfractive lesions, look at the grinding, look at the wear. What are we going to do for this patient? And most of those dentists are going to say, we're going to make a flat plane splint. We can't do anything wrong by making a flat plane splint. We're just going to protect any work that we do by doing it. Eh, wrong. What if I told you that if that patient happened to have sleep apnea, which by the way, is something that we see a lot of grinding with. Now, not all grinding comes from sleep apnea, but patients with sleep apnea are more likely to BRUX. So we better rule that out. Why? Because if this patient does happen to have a sleep related breathing disorder, then the likelihood that we're going to make their apnea hypopnea index higher is more than 50%. Let me repeat that. If this patient has apnea, then by making a flat plane splint that allows the patient to go easily retrusive, the likelihood that we're going to make their apnea worse is really high. First rule, do no harm. So I think we need to be thinking about everything we do in dentistry in terms of ruling out a sleep related breathing disorder. And we should have been thinking this way all along. So while we're on the topic of sleep BRUXism, I just thought I would throw this out there because, you know, there's a lot of thoughts out there as to why people BRUX. And one of the most common things that I hear from people that I'm teaching is that, oh, I understand BRUXism as an attempt to open the airway. And actually, we don't have any literature that supports that. What the literature does support is that this is actually a sympathetic response to an arousal from sleep. So somebody has an event that makes them go from a deeper stage of sleep to a lighter stage of sleep. And typically, that's a respiratory event like we see with sleep apnea. And during that process, as a rush of catecholamines, we get a sympathetic response. And then there'll be all this aberrant muscle movement. So watch this video, and it's going to explain exactly the point that I'm trying to make to you now. So on a polysomnogram, typically what we would see is that aberrant muscle movement. And it always happens after the sympathetic response. This is not an attempt to open the airway. This is the result of a sympathetic response to an arousal. And in this case, you heard the snoring. That arousal came from a respiratory event. And that's the kind of thing that all dentists need to be aware of. So when we talked about all of the practice outcomes that are affected by sleep apnea, I purposely left one off. And that one is pedo-ortho growth and development. Because if we're going to talk about the why, the why as to why every dentist ought to be doing this, I'm going to explain to you my why. So I moved to Conway, South Carolina, at the time just a suburb outside of Myrtle Beach. Pretty small area when I moved here, although it's really boomed since then. We had one pediatric dentist and one orthodontist for the entire county. So you can imagine the backlog of children. Well, I decided to be smart if I wanted to build a practice. I was going to go off and learn pedo-ortho growth and development, because all of these kids needed somewhere to go. And I was going to be that person. So my why was watching growth and development and doing functional appliances for children, expanding arches, making airways bigger, making children grow better. And I got to do this for now 30 years. And I've watched the kids that I was able to make an impact for. And I've watched the kids that I was able to jump in and provide treatment for turn into healthy adults who are now bringing me their children. But I've also gotten to watch some of the kids that I wasn't able to make an impact for. And unfortunately, this is a disease, sleep-related breathing disorders, is a disease that typically starts in childhood. And so I watched a lot of these kids go from children that I could have helped. Maybe they couldn't afford it. Maybe they weren't prepared. Maybe I wasn't convincing enough. But I watched a lot of those kids go on to become adult apnex, who I also happen to be treating right now. So I came through in the early 90s. As I said, we were working with a lot of functional appliances. We were bringing mandibles forward. We were expanding arches. Expanding arches makes the nasal volume larger, so kids were breathing better. Even some of the kids with tonsil and adenoid hypertrophy, even some of them, we were able to get better to where they didn't need the surgery to have the tonsils removed. And of course, that's a case-by-case basis. But at a time where it was really difficult to get kids approved for tonsillectomy and adenoidectomy, this was an absolute lifesaver. So these things worked. And it was in the mid-90s that the AADSM really kind of came around and said, hey, we can really be making a big impact, not just for children, but for adults as well. So when I talk about the why, my why is what I've been able to do for children and what I continue to do for children and help them grow up to be healthy adults. And the thanks and the gratitude that I get from the families when I do that. And if you don't think this is a real thing, I ask you just to watch this video. And if it doesn't elicit some kind of an emotional response, I'd be really surprised. So that video is called Finding Connor Deegan. You can find it all over YouTube. Valerie Deegan, the mom, has actually been to several dental obstructive sleep apnea and sleep disordered breathing meetings. She wants this message out there. She wants dentists using this. She wants everyone to know the impact that dentists can have on a child's health, growth, and development. So can dentists really make a difference? I think that that video gave you the answer to that rhetorical question. Of course, dentists can make a huge difference. And in fact, we can make a difference through an entire lifespan. This is a lecture that I did out at the Coyce Center. I used to be the scientific advisor on sleep out there with Dr. John Coyce. And I had the pleasure of doing this presentation called Managing Airway Risks from Conception to Culmination. And so we talked about how sleep disordered breathing has an impact throughout an entire lifespan. And this is why we all need to be doing this, because we're all seeing these patients throughout their entire lifespan. And there's a risk there through that entire time. So when we talk about sleep disordered breathing, I think most people think it's only about oxygen. It's only about air. Are we getting enough air? Are we getting enough oxygen? And yes, that's a major part of what sleep apnea is. But we also have to remember that there are other factors involved here, like sleep. So let's talk first about the oxygen. We know that there are risks that are associated with acute hypoxia. What happens when our oxygen levels go down? We don't think clearly. We get nauseous. Maybe we have some vomiting. Obviously, we'll have some dizziness, a headache. If any of you've gone to Pikes Peak or climbed to a high elevation area, you may have felt some of those symptoms. And certainly, when hypoxia reaches a certain level, we can lose consciousness. Well, with sleep apnea, what happens is we have many, many episodes of hypoxia over a long time. And so there are some risks that are associated with chronic hypoxia. And this is typically a lot of the things that we see our patients coming in with, and a lot of the things that cause the comorbidities that we're already seeing on our medical histories. Things like tired patients, patients expressing fatigue and hypersomnolence, high blood pressure. Many of them will have arrhythmias or dysrhythmias. A lot of people will have gastroesophageal reflux. They'll have increased risk for a heart attack, or maybe they've had a stroke or a TIA already. They are going to be at increased risk for type 2 diabetes. There'll be mood disorders, memory problems. We'll see cellular damage and cell death, which can make for earlier morbidity. So these are things that we have to be aware of. These are things that we have to be speaking to our patients about. Because again, if we're going to be more than just a tooth doctor and be a healthcare advocate, I think we need to be having these conversations. And what risks are associated with chronic hypoxia and obstructive sleep apnea? I always say, how much time do you have? I could talk to you about this for days, really. So of course, it's about oxygen. But I think the part that many people miss is that it's also about sleep. And many of these patients, the primary concern that they have is how tired they are during the day. The fact that they're having the nap. Maybe they're falling asleep at the wheel. Maybe it's putting them at high risk for accidents because they're in a job that requires driving or using high-powered equipment. So we need to be very aware that some patients are going to be suffering from the conditions associated with hypoxia, but a lot of patients are going to come to you with only symptoms that reveal that they may be very tired. And we have to take that very seriously because this condition is about oxygen, but it's also about sleep. Let's just be aware of that, and let's talk about some of the risks that are associated with sleep deprivation by itself. Let's take oxygen out of the mix altogether and talk about what sleep deprivation can do. We can have memory problems. We can have a difficult time concentrating. There will be hormonal changes that occur because we're not getting enough time in deep sleep where the parasympathetic nervous system can regulate all of our hormones and neurotransmitters. We can be at higher risk for accidents, certainly poor judgment and poor thinking. It weakens our immune system. It creates high blood pressure. It puts our risk for type 2 diabetes way up there and insulin resistance. It changes our hormones to the point where we feel hungrier more of the time. So these patients on top of the insulin resistance are going to have hormones that make them feel hungrier, so we'll see weight gain at the same time. It can affect our sex drive and our sexual functioning. It puts us at higher risk for heart disease. It can certainly cause poor balance and clumsiness. So you can see that sleep just has an impact on so many of our systems and why we have to be so aware that many of our patients are only complaining about sleep. They're not coming in saying, I think I may be hypoxic. So what's the problem here? If this is so easy to spot and so many of our patients have a lot of these symptoms, why aren't we diagnosing this condition more? I mean, this has such a huge impact on our medical delivery system. So this is a study by Krieger, and this was published all the way back in 1997, that said sleep apnea patients are going to use healthcare resources at twice the rate of controls as far back as 10 years before their diagnosis. And therein lies the problem is the fact that we're not getting this diagnosis until they're presenting with all of these horrible comorbidities and diseases that were typically caused or at least led into by having the sleep-related breathing disorder. We also know that hospitalization stays for patients with OSA is 2.8 times higher than those without OSA. So you can imagine the burden on our medical care system that this is having. So going back to what I call the crisis of the undiagnosed and what my vision is, first of all, we've been in this big trap. What has that trap been? The trap has been that we think that everyone out there with OSA is a old fat man and nothing could be further from the truth. Weight has a burden, age has a burden, certainly being a male has its own burden, but what we see in the medical system is a bias against diagnosing sleep apnea. And it's not that physicians don't want to diagnose it. It's just that very often the disease or the condition is ruled out because someone is not obese, because someone is not a male or because someone is not morbidly obese. And so therein lies a lot of the problem and therein lies the trap that we see. So I love this little pie graph because what this shows you is all of the people out there are suspected to have OSA or sleep-related breathing disorders. And we know that number to be somewhere between 25 and 40 million. Some people estimate that as high as almost 50 million if you're including all of the sleep-related breathing disorders. But here's the issue, is that as of the time of this report, which was 2014, only 10% of all OSA sufferers have been diagnosed. Let me repeat that. Only one out of 10 people with OSA have ever been diagnosed. Now here's the sadder part, is what typically happens when somebody gets diagnosed. They're automatically put on CPAP. And we know that the long-term success rate with CPAP is not that great. There are many studies that go all over the map. I can tell you those numbers are anywhere from 25 to 40% of CPAP users are long-term successful. I can tell you anecdotally from my practice that typically it's about a quarter or maybe even a little bit less that do well long-term and are compliant with CPAP. So think about that. If we're only diagnosing 10% of the population and only about a quarter of them are successfully treated or let's even say a third, we're only treating 2% to 3% successfully. I think that is abysmal. I mean, that is such a horrible statistic for medicine. I mean, for medicine in 2021, we just got to have a different vision. So my vision is one that comes from the lyrics of the great Neil Peart of the band Rush. I'd be remissed if I didn't mention the band Rush. Anyone who has seen me knows I am an absolute Rush fanatic. But Neil Peart wrote these lyrics saying, a spirit with a vision is a dream with a mission. My vision is to get more people diagnosed. The treatment is fairly easy. We have lots of ways to treat these patients. We don't all have to be making appliances. You may elect not to do that, but we have an obligation to be a healthcare advocate to our patients and to get these people diagnosed and treated. So what's wrong with the current medical model that that's not happening already? Well, there've been many studies done on this as to why we're not getting these patients diagnosed in the current medical model and through the primary care physician the way we would hope it would be happened. So this is a study that came out, it was published in the Journal of Clinical Sleep Medicine. And what they did was they looked at 101 primary care patients. And what they did was they used a test called the STOP questionnaire. And Dr. Hart will talk to you more about some of these screening tools that we have. So they use this screening questionnaire that asks people about, you know, stopping breathing and are they tired? Do they snore? And do they have high blood pressure? So, you know, at least they're asking the questions, which I think is the most important part of all of this. So 34% of the patients of the 101 were actually flagged for being at high risk for having OSA. Wonderful, because what we know statistically across the board, across different continents and countries and ethnicities, is that typically one out of every three people is going to be at higher risk for OSA just based on what we know and based on the metadata that's out there from all the studies that have been done. So any number that runs around that level, I'm saying they're in the ballpark already. So great. They went ahead and they did this screening tool. But here's the problem. Remember I talked about gender bias. I talked about weight bias. I talked about age bias. And unfortunately, some of these things are built in. And also the fact that primary care physicians don't have a lot of time with patients anymore. And they really need to get to a diagnosis and unfortunately a quick fix sometimes. So we end up treating symptoms. So going back, what percentage of patients do you think were sent for a sleep study? 2%. 2%. And the studies you will see throughout the literature, and it's getting a little better. We're getting our message out there. But that's why I'm doing this recording right now is because we've got to help the system. Three times more likely were patients to be referred for a psychiatric consult than for a sleep study after they had screened high risk with a well-known piece of data, a well-known questionnaire. So this is a crisis of the diagnosed because only two or three out of every hundred people with OSA have been successfully treated long term. Yet, the CPAP industry alone is a $5 billion, that's with a B, $5 billion a year industry. So what is that saying about the efficacy of what we're doing right now and the current model? Guess what, dentists? We can change this. This is our job to change this. And it's not something that we shouldn't be doing. Can we make a difference? I told you only throughout an entire lifespan, when we talk about the ways that we can impact patients all the way through, I think it's so compelling. If I'm going to make the argument as to why all of you should be screening for sleep-related breathing disorders, just listen to this. I'm going to go through every one of these age groups. So we know that during gestation, that sleep-disordered breathing is very common. 30% of all pregnant women are going to snore. That's from the Chest Journal, published as far back as the year 2000. We know that snoring is associated with a higher risk of sleep-disordered breathing. We also know that that's associated with a higher risk of gestational diabetes, pregnancy-induced hypertension and preeclampsia. So if we have the ability to screen our patients when they present to us, and don't assume all the OBGYNs are going to do this, we actually send a note to all of our OBGYNs saying we did a screening questionnaire, or the anatomy shows that this patient may be at higher risk. And the OBGYNs are very thankful that we're doing this. They don't feel like we're overstepping our boundaries. The risks during pregnancy to the unborn. We know that women who snore habitually are going to deliver developmentally delayed babies 7% of the time. But even if it's only occasional snoring, they're going to deliver developmentally delayed babies almost 2.5% of the time. So again, if we can have that impact that brings down premature deliveries, yes, from the dental chair, because we're screening. I'm not saying we are diagnosing, we are screening. We're getting these patients identified. What a service we're doing. Concerns for the newborn and for infants. You know, kids with sleep disorder breathing, and yes, they can be born with sleep disordered breathing. They'll be unable to breastfeed. They may have a tongue tie that makes that breastfeeding more difficult. They may have respiratory infections, vitamin D deficiencies, and certainly you can even hear snoring sometimes from inflamed lymphatic tissue. So we need to be considering all these things. And those risks go on into toddlers and pre-adolescents with frequent respiratory infections, frequent ear infections, frequent urination, and even bedwetting, poor school performance, hyperactivity, poor sleep, lots of allergies, enlarged tonsils and adenoids. We see a lot of these kids with a bad gag reflex, constricted arches, high palatal vaults. Constricted arches and high palatal vaults, you know what that means? That means a smaller nasal volume, so they may become an obligate mouth breather, which then affects growth and development. Snoring, witnessed apneas, these are all things that we need to be looking for in toddlers and pre-adolescents as well. I told you, that's what brought me into this whole thing. And guess what? Obesity is already a problem in the toddler and adolescent, pre-adolescent, and even adolescent age group. The good news is, as we see some of that weight gain go down during adolescence, but certainly what we know is that in America, we were already at a 16% obesity rate in the United States, and that is a huge number. So if you add weight and fat within the neck and trunk on top of inflamed lymphatic tissue, tonsils, and adenoids, now you've got kids that are really at high risk. But make that worse, all these kids staying home and not eating as well during COVID, we saw an increase in the obesity rate go from 16% to 17% to almost 19% to 22%. So this is an absolute pandemic that goes way beyond respiratory infection. We've also seen this affect adults. We saw that the average weight gain over a six-month period for both kids and adults has been between six and seven pounds during a six-month period during the pandemic. So we need to be aware of this, and we need to not have that age bias, particularly in the pre-adolescent and toddler age group. So moving on, we want to talk about some of the changes of concern during adolescence. Well, we know that there's going to be sleep patterning changes during adolescence. We know the kids are going to stay up later, wake up a little bit earlier, stay on the phone, stay on the computer. But guess what? That's all worsened by underlying sleep disordered breathing. We're going to see hormonal and behavioral changes that are part of adolescence. But unfortunately, if we're not getting enough deep sleep and good sleep architecture, we'll see those hormonal and behavioral changes worsen by underlying sleep disordered breathing. And on top of that, that we may start to see alcohol or drug use. And then there's another factor that may reduce the severity of the symptoms, but not get rid of the condition. And that is, like all pediatricians say, well, those tonsils will go down when they go through puberty. And yes, most of the time they will. But at what expense? We've lost all that growth and development. There's still underlying disease. It's just that we don't hear it as much because they're not snoring because the lymphatic tissues aren't as inflamed. And on top of that, we get closure of the growth plate. So it makes our curative therapies to make the palate wider, the nasal cavity and nasal breathing better. As we get into early adulthood, we see changes in dietary habits again. We'll typically start to see that weight gain come back that went away during adolescence. We'll see changes to sleep patterning because of the busy lifestyle. And again, that's going to be worsened by sleep disordered breathing. We're going to see dietary changes and a potential for further weight gain because of how busy people are and fast food and having to do things quickly and on the run. And certainly now because of the pandemic, we're going to see hormonal and behavioral changes that will be worsened by sleep disordered breathing, just like we did in the adolescent. Certainly we may see increased alcohol or drug use. And unfortunately, during this age period, there may not be a bed partner or a housemate that's going to recognize the symptoms to help get these patients diagnosed. And very often, the patient themself is not going to notice a problem. And certainly we have to talk about age, weight and gender bias, which is going to lower the diagnosis rate and the risk for comorbidities throughout adulthood. And now again, remember when I said, how much time do you have when we talk about the comorbidities associated with sleep related breathing disorders? Well, what we have here is a chart that shows many of the comorbidities seen along with obstructive sleep apnea and that based on that comorbidity or condition, the likelihood for someone testing positive for obstructive sleep apnea. So as we see these conditions that are typically and very often tipped off by sleep apnea, these are the conditions that we're seeing treated by the physicians, usually 10 years before we ever get that diagnosis of obstructive sleep apnea. So I'm saying just look at the medical histories and screen that way, because a patient that has hypertension, one in three of them is going to test positive for OSA. If they're drug resistant, meaning that they're on more than one medication or that they're still spiking while they're on that medication for hypertension, that likelihood goes up to 83% likelihood of OSA. Heart failure patients, three quarters of them are likely to have OSA. Heart failure patients, 85%. Half of your patients with atrial fib are going to test positive for OSA. How many patients do you have that have a history of atrial fib have been put on the table and shocked, put into cardioversion before ever even getting a sleep study to see if they have OSA, yet we know at least half of them are going to have OSA? If you've had a stroke or if you've had a TIA ischemic, then what we know is that nine out of 10 of those patients will test positive for OSA. Four out of 10 patients with ischemic heart disease are going to test positive for OSA. A third of refractory epileptics, half of all diabetics are going to be positive for OSA. If you're an obese diabetic, that goes up to almost three quarters of them are going to test positive for OSA. If you're a morbidly obese male, nine out of 10 of those patients are going to test positive for OSA, and half of those women are going to test positive for OSA. This is the one that really gets me because why are we not sending patients for sleep studies when they have nighttime GERD? Just by having GERD, just by having gastroesophageal reflux, the likelihood is 60% that a patient will test positive for OSA. If you change that to nighttime GERD that is not associated with late night eating, that number skyrockets to nearly 80 to 90%. So why aren't we asking those questions? All you've got to do is look at your medical histories. When we talk about obesity, we know that obesity rates went way up during the pandemic, but look at this number. This is in 2017 to 2018, the obesity rate was 42.4% in the United States. And just from 2000 to 2018, that number went up from 30% of the population to 42.4% of the population. Do you really think that this problem is going away, that the numbers I mentioned at the beginning of the lecture are getting any better? Of course they're not. And look at it. It goes across all these different aid groups. We're not just talking about fat, old males. We are talking about all people are seeing an increase in obesity. And so let's move on beyond the adults. Let's talk about the seniors now. We know that seniors now, as they get older and some of these comorbidities have taken more of a toll on their overall health, that will make the effects of the OSA or the sleep-related breathing disorder even worse. We know that as patients get older, particularly women, menopause is going to pose an increased risk for OSA associated with the hormonal changes. We know that the metabolic rate is going to go down. We know that these patients lose muscle tone. We know that there's increased medical compromise. And then certainly we know that OSA is going to increase the risk for heart attack, stroke, dementia, and early death. So when we talk about risk factors for heart attack and for stroke, we've done many studies on this. And, you know, looking at this study from the NIH, these are the independent predictors for future myocardial infarction. So just by virtue of being overweight, a patient has seven times the risk of controls of having a future MI. But if they're hypertensive, they have almost eight times the risk. If they're a smoker, they have 11 times the risk of controls. But if they have undiagnosed or untreated OSA, then they have almost 23 and 1 half times the risk of controls of having a future heart attack or stroke. This is laminated in every single operatory that I have. So when a patient says to me, so what, Jeff? Why are you talking to me about breathing and sleep? That's for my doctor. I hand this over, and I say, here's so what? Here's your risk for a heart attack. And by the way, you also happen to be an obese, hypertensive patient that smokes. So these are additive. So your risks are really getting out of control. And we can help mitigate those risks, yes, from the dental chair. So when we talk about all-cause mortality risk for age, sex, and BMI, we know that sleep disorder breathing severity increases that risk. So if they have severe sleep disorder breathing, it increases the risk by threefold. So if we look at the hazard ratio for cardiovascular mortality, now we look at a fivefold increase. And so the findings here in this study published in the Sleep Journal were that there's a significant high mortality risk with untreated sleep disordered breathing, independent of age, sex, and BMI. Remember the biases that we talked about, and a need for heightened clinical recognition. Very important. So the big question here, folks, I'm a dentist. Can I do this? Not only can you do this, you should be doing this. In 2006, the American Academy of Sleep Medicine, got together and said, you know what? We need to make a position paper saying that dentists should be treating sleep apnea because we are now only getting to 2% to 3% of all the people with OSA as far as successful treatment goes. So they came out with this position paper saying that oral appliances are indicated for use in patients with mild to moderate OSA, or if they prefer them to continuous positive airway pressure, and that we can even use it in severe apnea if the patient fails or refuses CPAP therapy. They cleaned a lot of these up. I'm not going to spend a lot of time here. You can certainly go to the AADSM website to read all of these position papers. I'm just trying to make the point that we have all of these groups saying, not only can we be screening for OSA, but we should be screening for OSA and working in conjunction with our physician and medical counterparts to get these patients diagnosed and appropriately treated. So I encourage you to go back and read these guidelines in detail. I'm not going to read them to you right here. I was so frustrated back in 2015 that we still didn't have a position from the Academy of General Dentistry or from the American Dental Association supporting dentists in their quest to screen and treat sleep apnea, that I actually helped co-author a resolution for the House of Delegates back in 2016 that said just this, resolve that the Academy of General Dentistry supports qualified dentists providing treatment for OSA with custom titratable oral appliances when prescribed by a referring physician. And be it further resolved that the AGD supports dentists in the oversight of patients in appliance therapy for OSA in conjunction with a sleep physician to improve or confirm treatment efficacy. Not only can we do it, we should be doing it. Unanimous consent on this resolution. So what happened the next year? The ADA came out with their position paper. I'm not going to read this whole position, but what I want you to do is go back and read it to see how well supported you are in doing this. So when we talk about what sleep apnea is, I think it's important that we be able to convey this very succinctly to our patients. I'd like you to watch this brief video. This is a video that with permission, I would encourage you to either show or discuss with your patients the highlights. This is courtesy of the Mayo Clinic, and I think it's a beautifully done video as far as being succinct. When you're awake, muscles keep that pathway relatively wide open. But when you sleep, those muscles relax, allowing the opening to narrow. The air passing through this narrowed opening may cause the throat to vibrate. That causes snoring, which many people experience. But in some people, the throat closes so much that enough air can't get through to the lungs. When this happens, the brain sends an alarm to open the airway. Most often, this is associated with a brief arousal from sleep. The brain quickly reactivates the muscles that hold the throat open. Air gets through again, and the brain goes back to sleep. This disorder is called obstructive sleep apnea. So if that's what apnea looks like anatomically, what does apnea look like graphically? I think this is really a nice little graph for dentists to look at just to see what happens and what you witnessed in that cycle and what you're going to witness in the video that follows this. So when a patient goes to sleep, the muscles are going to begin to relax as a patient goes into a deeper level of sleep. We'll then see the airway get a little bit smaller. As the airway gets smaller, the air can become more turbulent and cause negative pressure. And when that happens, we get vibration. That's heard as snoring. But when we get a smaller amount of air passing through the airway, we can start to become slightly hypoxic. It will typically happen at a slow rate as the airway gets smaller, but we will continue losing oxygen. And then CO2 levels will increase as that's happening. When we become hypercapnic, the CO2 receptors in the carotid bodies and in the brain will then tell us that we're suffocating, that we're losing oxygen, and that CO2 levels are increasing. So the body is going to shut off deep sleep. It's going to shut off the parasympathetic nervous system and kick in the sympathetic nervous system and create an arousal. So what's going to happen is the body's going to say, hey, we need to be breathing. So it's going to increase heart rate, increase blood pressure, and it's going to increase ventilatory drive. When that happens, we can get a harder breathing, a more forceful breathing, which can then further suck down the airway because of negative pressure. So we call that increased ventilatory effort. And that can be the coup de grace, so to speak, in what closes the airway the rest of the way and the patient can go from a partial apnea or a partial closure of the airway to a full closure. So we finally get that arousal where the patient moves around and we get that muscle movement. The airway opens and then the patient will hyperventilate and that's going to happen over and over again throughout the night. And it can happen hundreds of times for the average patient. If that's the graph, then this is what it looks like in reality. Here's a video that shows somebody who is having apnea after apnea. So I think you all get it. You know what this looks like anatomically. You know what it looks like graphically and you kind of understand what we're talking about when we talk about apnea. So how is this relayed between health professionals? We talk about apnea as a combination of events. We talk about apnea as any event that causes at least a 4% decrease in oxygenation any event that causes a 30% flow limitation in airflow or any event that lasts for more than 10 seconds without air. So we call the events with 30% blockage and a 4% decrease a partial apnea or a hypopnea and we call the 10 second breathing stoppages or flow limitations apneas. So we have to remember apnea the condition is actually a combination of events. It is apneas and it is partial apneas and it can be any combination of those events. It can be all partial apneas or hypopneas. It can be all apneas or can be any combination. We take the total number of events that caused an arousal the total number of apneas and the total number of hypopneas throughout the time asleep divide that by the time that the patient spent asleep and we get this apnea hypopnea index which I will tell you is the gold standard for diagnosis but I will also tell you should be accepted with a grain of salt because this is giving you the number of events that somebody is having in a given hour not necessarily the severity of each of those events but across the literature this is the gold standard and this is the main communication tool that we have for measuring sleep apnea. So if someone's having 5 to 15 events in a given hour they're considered to be mild if that number is 15 to 30 events they're considered to be moderate or have moderate apnea and if they have more than 30 events in an hour they're considered to be a severe apnea. How do these patients present? Most common symptoms of sleep apnea snoring and excessive daytime sleepiness. So what does that mean? What that means is all you need to do is ask and listen doctors. You know there are two questions that you can ask very easily during every hygiene exam during every new patient exam and the way that I sneak these in is I will do it after I do my oral cancer screening because I'm already looking at the tissues in the back of the throat and so that's my lead-in as to why I would be talking about snoring. So the questions I will ask are these would your bed partner or housemate say you ever snored? Because if we ask the patient directly do you snore? A lot of patients aren't going to admit it. The other question that we'll ask is do you ever have difficulty staying asleep or do you ever feel tired during the day? Again these are just lead-ins these are not definitive diagnoses these are just lead-ins and if I had to tell you one of the best screening tools we have it's simply asking these two questions for the two primary symptoms of obstructive sleep apnea. What are the other powers that we have as a dentist without not overburdening you? We can look for things like acid reflux and this is readily visible in the mouth as reddening as acid erosion on the teeth. Dr. Hart will cover this in great detail about the things we need to be looking for during the clinical examination but looking is certainly an option. We know sometimes people lie when we ask and we talk to them so we have tools like Conebeam this is not a course on Conebeam I just want you to know all of the tools that are available out there to screen as you begin seeing and recognizing that nearly a third of the patients walking through your practice are going to be at high risk so many of the Conebeam companies out there now have airway management tools and airway management software that let you look at risk for sleep disordered breathing. You know even if a patient comes in and they're asking you for implants what stops you from looking at the sagittal or the coronal or the axial image of the airway to see what it looks like we need to see narrowing when the patient is standing up and awake because we know that that's typically only going to get worse during sleep so we have the ability to be screening just by looking. Later on as you become more adept and as you get more into the education and the tools that are out there we can use tools like acoustic reflection using sound waves to look at what happens to the airway. We can look at things like malampati classification we can look at pharyngeal grading and don't worry Dr. Hart is going to cover these beautifully during the clinical exam so we can look at the north-south dimension of the airway and malampati we can look at the east-west dimension with pharyngeal grading we can look at the tongues we can look at the airway you know I have this saying black is good, pink is bad, red is worse you see a lot of black there during the examination that's a good sign if you see a lot of pink back there and no black airway that's bad but if you see no black and you see a lot of red that's really bad that tells you not only is there a lot of swelling and inflammation but that these structures are large and they're blocking the airway we can look at the level of the tongue we can look for scalloping again Dr. Hart will cover tongue level grading during his presentation I just want to alert you to all the things we could be looking for and understanding that this is a disease that starts in kids don't just ask you know the older patients don't have the gender and age and weight bias that most health care practitioners have when they start talking about this and remember in the kids the same saying goes black is good, pink is bad, red is worse so when we see those large hypertrophic tonsils excuse me we know we should be thinking about an ENT referral or thinking about arch expansion or thinking about myofunctional therapy or a combination of the three Dr. Hart will expand on that during his presentation it's the same things that apply black is good, pink is bad, red is worse we can look at our scans again for tonsils and adenoids and tonsils are pretty easy to see although we see some lingual tonsils on the scan that we would never see in the mouth and certainly we can see the adenoidal tissue on a CBCT in the sagittal view you know I tell all dentists to look for the C words especially in kids cross bites, crowding, and constricted arches these are telltale signs that there may be a sleep disordered breathing problem how long does it take you to go through the C's is there a cross bite is there crowding is there a constricted arch so easy we can do things like arch development and this is not a course on how to do that I just want you to recognize the possibilities because not only can we help recognize these patients but with proper training and with the AADSM and their tools we can learn also how to help take care of these patients and create healthier patients I told you I've been doing this for a long time we've all been doing this for a long time and now with the recognition of the AADSM and the ADA and the AGD and the AASM now we're in the position to be doing this why do I do this it's because of patients like this this is a young lady who is being made fun of because of her buck teeth she didn't like the spacing she was crying all the time behavioral issues you know lots of concerns here and you know believe it or not the tonsils and adenoids weren't that big on her I said how does she sleep mom said she doesn't sleep and I said well we're gonna change that and tonsils and adenoids weren't really big enough for even a referral at that point I said let's do some arch expansion let's go ahead and close this up a little bit let's bring the arches closer to each other and let's make her let's make her look and feel a little bit better and by the way I think we're gonna see her sleeping better so what did we do we went to a liner therapy with a mandibular advancement tool we expanded her arches beautifully we brought her lower jaw forward we started correcting the skeletal discrepancy at this point we allowed for passive eruption posteriorly to open the bite a little bit and this is what happened as of that October now this is only four months this is what she looked like in the aligner therapy at four months that is her new posture we're allowing passive eruption we've widened out the arches we've brought the anterior teeth together and guess what not only did we see an improvement in the way that she looks and the way that she feels but we saw a growth spurt during that four months that does not even look like the same young lady in a four-month period ladies and gentlemen that's my why that's why I do this that's why I want more of you recognizing these kids even if you decide that doing appliance therapy and getting deep in the trenches of appliance therapy is not for you at least learn it use the ADSM as a tool for you and your education to at least be aware of all the areas of dentistry that this affects my why is I made a confident young lady I gave her better school performance we helped improve her behavior we certainly improved her growth we got her back on the growth chart to a more normal place we improved her health but we have a mom that can't believe that the dentist has all of these powers and these people will never leave my practice and I've got generations now of doing this and if you don't think that that has an impact on how passionate you are about your career well then you're missing something because that's why I will continue to do this until the day I can't do it anymore these patients are never going to leave my practice and they're going to tell everyone so the ADSM can provide all the tools you need for dentists to impact the crisis of the undiagnosed we can provide more comprehensive diagnoses that lead to other indicated procedures I call that the hidden annuity of sleep people see the kind of care you offer and they say I want to use you as a dentist I want to be in this practice you're a caring person we can decrease patient risks medically and dentally I talked to you about risk management and by doing risk management and really sticking to those principles we can decrease our overhead and increase our efficiency less chair time means more profitability people and we're going to provide a true quality of life service that saves lives and I think we're creating goodwill with the medical community we're going to increase our referrals from the medical community not just for sleep but for the other services because they see that we are out for our patients health so start screening now go to the adsm.org site they have all the tools that you will need there I will tell you it requires minimal doctor time minimal doctor effort and you will get maximum gratification from this coming up is Dr. Christopher Hart great guy brilliant guy fellow diplomat I talked to you about the why and he's going to talk to you about the how we do that in clinical practice I'll leave you with this final thought to say your beliefs don't make you a better person your behavior does there's my email address again at the bottom of the screen I would encourage you to please email me if you have any questions about this presentation or about anything regarding sleep related breathing disorders or if you just want to chat you can certainly visit me on our Facebook page Dennis in the know where we just have good open honest conversation about the current trends in dentistry and what's going on in dentistry we see our job as as helping bring all of our attendees in the know I hope I brought you in the know a little bit today and with that I will say a big thank you to the adsm for giving me this platform a thank you to Christopher Hart for his upcoming segment and I hope all of you become involved in sleep disordered breathing identification thank you

sleep-related breathing disorders

sleep apnea

screening

dentists

medical community collaboration

etiology

prevalence

risks

comorbidities

oral appliance therapy