Archives for category: DSM

 WHAT IS SLEEP COORDINATOR ACADEMY?

Every dentist wants to develop a strong presence in the exciting and profitable world of Dental Sleep Medicine. We have all heard the stories of phenomenal success some dentists have in treating patients for Obstructive Sleep Apnea.   There are approximately 200,000 licensed dentists in the USA and as of last year less than 5% of them are qualified to treat the millions of sleep apnea afflicted patients. Why such a disparity? The most common responses are, “I’m too busy to learn a new service.”,  “My staff is too busy.”,  “I don’t know where to begin.”

DO YOU SEE THE COMMONALITY?  

But we do have a solution for them

In comes Sleep Coordinator Academy, wearing a shiny suit of armor, on her/his white horse, and says, “ Doctor, I have the solution for you. I will provide you with a comprehensively trained sleep coordinator who will establish a dental sleep medicine service in your practice for you and s/he will handle all the screening of your patients, marketing for new patients, present the case plan (sell), manage the medical billing and record-keeping and assist you in taking the impressions and adjusting the appliances. S/he may be in independent contractor and you can work out the schedule of days and hours with her. 

Sleep Coordinator Academy presents an A to Z practical training course that prepares the candidates for a confident position in the most highly respected Dental Offices and after graduation assists in placement and follow up.  

You may email me with any questions

Abfractions- Common in patients with Obstructive Sleep Apnea.
Nocturnal bruxism, which is indicative of OSA, plays a major role. The effective solution requires treatment of the causes- OSA with occlusal imbalance.
 
Abfractions are non-carious cervical lesions (NCCL) caused by flexural forces; the enamel, especially at the cemento-enamel junction (CEJ), undergoes this pattern of destruction by separating the enamel rods.  Studies show that within the same patient, teeth with abfractions presented more gingival attachment loss than those without abfractions.  
 
 

 

An abfraction occurs on the lower part of the crown of a tooth, near the gum line.

            The enamel covering the crown tapers down to its thinnest there.  Uneven pressures on the biting surfaces of teeth cause a torque on the tooth which produces a slight bend at the center where the crown meets the root. As the tooth keeps bending, the thin enamel at the bottom of the crown, near the gum line, chips away.

 

The sensitive “dentin” surface inside the enamel is now exposed. Vigorous, improper teeth brushing will then wear away the unprotected dentin and the notches will grow deeper and larger.  The dentin also becomes vulnerable to acid erosion from foods such as citrus.

 

 

#3  THE ORAL MANIFESTATIONS OF OSA 

NOCTURNAL BRUXISM

The coincidence is very high between Obstructive Sleep Apnea  and grinding and bruxing while asleep.
Most of the sleep bruxism events happen when a subject is lying on his or her back.
Immediately after the apnea episode, when the ventilation process resumes, activation of the process of jaw-opening and closing begins. This is an involuntary effort to dilate the upper airway and reduce the resistance in order to ease normal breathing.  
This continuous, repeated process of empty-mouth mastication throughout a night of apnea events causes wear on the occlusal surfaces and incisal edges which is readily detected in a dental exam.  
There is a marked decrease of nocturnal bruxism when apnea/hypopnea episodes are completely eliminated.
 
 
 
   

1. Mallampati Airway Exam  

2. Scalloped tongue

 

 

During an apnic event the tongue will force itself forward to remove itself as an air-blocking barrier.  Repeated compressions like this, pushing against the teeth, will leave impressions in the lateral edges of the tongue. The patient subconsciously  tries to force the tongue to move forward from the air tract and forces it against the teeth.This sign is readily detectable. This is also called Crenulated Tongue.

 
This indicator is nearly infallible; it must be differentiated from a similar condition (sign) in  a thyroid disorder.
 
 
We are in an excellent position to screen for sleep apnea and to help identify our undiagnosed (and therefore, untreated) OSA patients.
How can you miss these clinical signs?
You…..
• have direct observational access to the physiological structures of your patients’ upper airways
• are already screening chair side for other health conditions that can be easily spotted during a dental visit
• may see these patients more frequently than primary care physicians will, and are nearly one quarter more likely to see a dentist than a physician over any given time period.

Your field of operations is right next to the opening of the airway.

1. Mallampati Airway Exam

  

2. Scalloped tongue

During an apnic event the tongue will force itself forward to remove itself as an air-blocking barrier.  Repeated compressions like this, pushing against the teeth, will leave impressions in the lateral edges of the tongue. The patient subconsciously  tries to force the tongue to move forward from the air tract and forces it against the teeth.This sign is readily detectable. This is also called Crenulated Tongue.

This indicator is nearly infallible; it must be differentiated from a similar condition (sign) in  a thyroid disorder.
We are in an excellent position to screen for sleep apnea and to help identify our undiagnosed (and therefore, untreated) OSA patients.
How can you miss these clinical signs?
You…..
• have direct observational access to the physiological structures of your patients’ upper airways
• are already screening chair side for other health conditions that can be easily spotted during a dental visit
• may see these patients more frequently than primary care physicians will, and are nearly one quarter more likely to see a dentist than a physician over any given time period.

Your field of operations is right next to the opening of the airway.

                  MALLAMPATI EXAM

The Mallampati Scale is a simple but effective test to assess your patient’s (or your own) airway .

The subject should be sitting or standing with their head on a 90 degree axis to the floor.
They protrude their tongue (not necessary to say “ahh”) and with a direct light into the  mouth, look in and/ or take a picture.
 
Class III or IV conditions are certain candidates for further testing and possible therapy.
The tongue is the most common factor in Obstructive Sleep Apnea.

Now that you learned this you will probably be heading for a mirror. How did you rate?                                     

                                  MALLAMPATI EXAM

The Mallampati Scale is a simple but effective test to assess your patient’s (or your own) airway .

The subject should be sitting or standing with their head on a 90 degree axis to the floor. They protrude their tongue (not necessary to say “ahh”) and with a direct light into the  mouth, look in and/ or take a picture.
 
Class III or IV conditions are certain candidates for further testing and possible therapy.
The tongue is the most common factor in Obstructive Sleep Apnea.
Now that you learned this you will probably be heading for a mirror. How did you rate?   

WHY WOMEN ARE LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA

By Charles Kravitz, DDS in Women’s Health
Swedish scientist Dr. Karl Franklin and his team set out to find out how prevalent sleep apnea is among women and how often symptoms occur. Out of a population-based random sample of 10,000 women between the ages of 20 and 70 years, they gathered data on 400 of them. The test group were given questionnaires which included several questions regarding their sleeping habits and sleep quality. They also underwent overnight polysomnography.

WOMEN ARE LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA

Women with sleep apnea are less likely to be diagnosed compared to men. In studies of patients registering for evaluation for sleep apnea, the ratio of men to women has sometimes been extremely lopsided, with 8 or 9 men diagnosed with obstructive sleep apnea (OSA) for each woman found to have OSA. However, we know from studies in the general population that the actual ratio is likely to be closer to 2 or 3 men with OSA for each woman who has the condition.  Women make up about 45 percent of sleep study referrals and most sleep studies are still done to screen for sleep apnea.

WHY ARE WOMEN LESS LIKELY TO BE DIAGNOSED FOR SLEEP APNEA?

 First, there is an unfortunate predefined notion of the make-up of a sleep apnea patient. The stereotype is a middle-age, overweight or obese male. Physicians may not be thinking of this OSA diagnosis when the patient is female. Second, women may present with slightly different symptoms than the “classic” symptoms of snoring, witnessed breathing pauses at night and excessive sleepiness during the day.

Instead, women may present with fatigue, insomnia, disrupted sleep, chronic fatigue and depression morning headaches, mood disturbances or other symptoms that may suggest reasons other than OSA for their symptoms. Because these symptoms are not specific for OSA, women may be misdiagnosed and are less likely to be referred to a sleep study for further evaluation. Another problem is that women with sleep apnea have more subtle breathing disturbances and are more likely to have REM-related apneas, so they may be tougher to diagnose.

COMMON SLEEP APNEA MISDIAGNOSES
Women are often diagnosed in error with one of the following conditions, rather than sleep apnea.
  • Anemia
  • Cardiac or pulmonary illnesses
  • Depression
  • Diabetes
  • Fatigue from overwork
  • Fibromyalgia
  • Hypertension
  • Hypochondria
  • Hypothyroidism
  • Insomnia
  • Menopausal changes
  • Obesity

Sources

Dr. Karl Franklin, European Respiratory Journal

Grace W. Pien MD, MS, assistant professor of medicine, divisions of Sleep Medicine and Pulmonary and Critical Care at the University of Pennsylvania School of Medicine.

Nancy A. Collop , MD, medical director at Johns Hopkins Hospital Sleep Disorders Center and associate professor of medicine atHopkins’ Division of Pulmonary and Critical Care Medicine in Baltimore, Md .

Fiona C. Baker, PhD, sleep physiologist, Center for Health Sciences, SRI International, in Menlo Park, Calif.

Anita L. Blosser, MD, with Duke Primary Care at the Henderson Family Medicine Clinic in Henderson, N.C.

We know that men are more at risk of developing obstructive sleep apnea. But for women who suffer from OSA the risk of developing cancer is more than your male counterparts, says a recent research published in the European Respiratory Journal. During the study the scientists collected data of 20,000 patients with OSA. It was found that a large per cent of these patients were later diagnosed with cancer.

Researchers analysed data based on age, gender, alcohol consumption, body mass index and smoking. Again, there was a strong association between sleep apnea and higher cancer prevalence. Additionally, the link was stronger in women than men.

How Sleep Apnea Influences Cancer

The studies show that people suffering from sleep-disordered breathing have an increased risk of developing cancer and are up to five times more likely to die from the disease.
Once again the culprit is HYPOXIA. The lack of oxygen (hypoxia) caused by untreated Obstructive Sleep Apnea (OSA) can be a catalyst for a process called neovascularization (the creation of new blood vessels), giving a blood supply that can encourage tumor growth.

Sleep apnea leads to neurochemical imbalances. When poor sleep is the result of any untreated sleep disorder, the neurochemical balance that a whole-body process like sleep requires is disrupted.

 Two of the key hormones that fall out of balance—cortisol and melatonin—are critical for maintaining a healthy immune system (cortisol) and for regulating the body’s circadian system (melatonin). In addition, this neurochemical balance can lead to body-wide (systemic) inflammation.

 

How does this relate to cancer?

  • Without a healthy immune system, the body can struggle to fight off the aggressive cellular behaviors that can lead to tumors.
  • With an imbalance in circadian rhythms as the result of decreased melatonin, the body produces higher amounts of other substances that are risk factors for cancer (for women, higher estrogen can lead to breast cancer, and for men, higher estrogen can lead to prostate, bowel, lung, and bladder cancer).
  • Systemic inflammation causes oxidative stress to the organs. Oxidation is a breakdown of tissues that is the consequence of long-term inflammation; oxidative stress refers to the damage that results from unchecked systemic inflammation, which makes it easier for cancer—an opportunistic disease—to establish itself wherever the body is most vulnerable.

Cancer cells thrive in a low oxygen environment. Hospitals will put a patient on oxygen if their O2 levels drop below 92. Untreated OSA can cause oxygen levels to drop anywhere from the 90’s, 80’s and even in the 50’s.

Sleep apnea causes sustained low blood oxygen. 

One of the biggest problems with sleep apnea is the way in which it deprives the body of necessary oxygen. Frequent apneas (pauses in breathing that last at least 10 seconds, but often last much longer) lead to nocturnal intermittent hypoxia. 

Conclusion

Detecting OSA and leading the way for treatment can add YEARS to a  patient’s lifespan while significantly improving quality of life. Both cancer and OSA have symptoms that can be easily recognized in the chair during a regular checkup. While checking the mouth for masses and swelling, you can also check on the Mallampati score  and be alert to possible concerns you may have. 

                  MALLAMPATI EXAM

 

 More case studies

A 2012 study identified a link between sleep and aggressive breast cancers.  Ref: American Cancer Society 

In 2013, Spanish researchers reported that people with severe sleep apnea had a 65 percent increased risk for cancer. They suggested the risk is associated with increased hypoxia, a condition where the body is deprived of oxygen.

Another study from the University of Wisconsin found people with sleep-disordered breathing are five times more likely to die from cancer than people without sleep apnea. Researchers from the American study admit the study is limited in that there are no studies to compare it with that look at cancer survival in people with sleep apnea.

One recent study reported in the Journal of Sleep Medicine shows moderate and severe cases of sleep apnea are associated with increased cancer risk. That study also showed an increased risk for all “all-cause mortality” and cancer mortality due to cancer. The 20-year study showed that people with moderate to severe cases of sleep apnea are two and a half times more likely to develop cancer and three times more likely to die from cancer. The authors noted these findings confirmed previous research conducted by American and Spanish researchers. 

Animal studies have also confirmed previous findings. One 2014 study  reported in the journal Cancer Research linked sleep apnea with aggressive cancer growth in mouse models. Mice with tumors were placed in low oxygen environments that mimic the effects of sleep apnea and tumor growth in the mice progressed rapidly.

  

Researchers have also suggested a correlation between sleep apnea and increased cancer risk of any kind.   Risk of some cancers may increase. One Cancer study of 1,240 participants who underwent colonoscopies found that those who slept fewer than six hours a night had a 50 percent spike in risk of colorectal adenomas, which can turn malignant over time.
 
Sources: 

American Sleep Apnea Association
Centers for Disease Control
Mayo Clinic
National Institutes of Health
National Sleep Foundation
The New York Times
Wisconsin Cohort Study
World Health Organization

CANCER IS AN INCREASED RISK FOR WOMEN IF THEY HAVE SLEEP APNEA

We know that men are more at risk of developing sleep apnea. But if you are a woman and you suffer from obstructive sleep apnea (OSA) your risk of developing cancer is more than your male counterparts, says a recent research published in the European Respiratory Journal. During the study the scientists collected data of 20,000 patients with OSA. It was found that around 2 per cent of these patients were later diagnosed with cancer.

Researchers analysed data based on age, gender, body mass index and smoking. Again, there was a strong association between sleep apnea and higher cancer prevalence. Additionally, the link was stronger in women than men.

A 2012 study identified a link between sleep and aggressive breast cancers. Ref: American Cancer Society

ADDITIONAL CASE STUDIES

In 2013, Spanish researchers reported that people with severe sleep apnea had a 65 percent increased risk for cancer. The risk is associated with increased hypoxia.

Another study from the Univ. of Wisconsin found people with sleep-disordered breathing are five times more likely to die from cancer than people without sleep apnea. 

One recent study reported in the Journal of Sleep Medicine shows moderate and severe cases of sleep apnea are associated with increased cancer risk. That study also showed an increased risk for all “all-cause mortality” and cancer mortality due to cancer. The 20-year study showed that people with moderate to severe cases of sleep apnea are two and a half times more likely to develop cancer and three times more likely to die from cancer. The authors noted these findings confirmed previous research conducted by American and Spanish researchers.

 With a convincing condemnation of Sleep Apnea as a cause of cancer we need to be more serious about screening patients for cancer and OSA.