We examine how dentists can support patients.
Dentistry’s role in helping patients with this group of sleep disorders, is pivotal. As medical professionals we work with patients to enhance their oral and overall wellbeing, this includes airways. There cannot be a distinction between oral health and wellbeing, the airway being the gateway to the rest of the body.
Asking about sleep
Assessing the airway should be part of a dentist’s protocol at check-ups. If you see a restricted airway or a tongue not allowing you to view the airway, your next step should be to screen the patient for a potential sleep and breathing disorder, snoring or obstructive sleep apnoea. This includes patients presenting with bruxism, TMD and/or facial pain.
Assessing the airway should be part of a dentist’s protocol at check-ups."
The medical questionnaire completed by patients visiting your practice is an opportunity to gather the information you need. Adding two or three questions about sleep quality, how refreshed they feel on waking or if they have a headache or jaw pain, can indicate whether the patient requires a targeted assessment for any underlying sleep disorder.
Signs and symptoms
Restricted airways can be visible in some patients, but the most common presenting complaints are of snoring and/or excessive daytime sleepiness. When inspecting a patient, you should be able to see the back of the throat and the airway. A very narrow airway and restricted jaw opening, or a scalloped tongue, suggest the tongue doesn’t have enough room to sit comfortably and is pressed against the lingual/palatal surface of the teeth, or the patient is bruxing.
If a patient has a vaulted palate, the tongue is unable to be positioned comfortably in the oral cavity and may obstruct the airway. If younger patients are mouth breathing it does not allow the whole nasal floor or palate to develop correctly, anyone unable to breathe through the nose can subsequently develop an airway disorder such as sleep apnoea.
Sleep apnoea sets up an inflammatory process in the whole body."
Due to the mechanism of the disease, sleep apnoea sets up an inflammatory process in the whole body. This causes a metabolic chain increasing the risk of untreated patients developing metabolic diseases such as type 2 diabetes, cardiovascular disease, hypertension and stroke, with increasing evidence toward development of dementia.
Untreated sleep apnoea can lead to poor response to hypertension medication, so a patient on a cocktail of hypertensive medication should be assessed.
While the role of dentists is pivotal, the hygienists also play an important part.
Hygienists can see the airway clearly when inspecting the mouth in detail and can pick up and identify patients to refer to a trained dentist or a sleep specialist. Due to inflammation, sleep apnoea predisposes patients to develop periodontal disease or respond poorly to treatment.
Dentists should always work within their scope of practice, using the most suitable medical devices for optimum treatment outcomes to minimise potential complications during treatment. Once patients have been assessed fully and you suspect a sleep disorder, refer them for a sleep test or provide one if you have the appropriate training.
Dentists should always work within their scope of practice."
It is important to note that sleep tests must always be reported by a sleep physician or physiologist, it is not within our scope of practice to diagnose medical conditions. NICE Guidelines state that treating patients with sleep disordered breathing using a Mandibular Advancement Device (MAD), must be delivered by suitably trained dentists, who must ideally have knowledge of more than one MAD.
A confirmed diagnosis will confirm what course of treatment to recommend. For sleepy patients, the ‘gold standard’ is Continuous Positive Airway Pressure (CPAP). The usual trial would be two weeks, but if the patient is resistant to it, a MAD is considered. Some of these patients are candidates for skeletal osteotomies or soft tissue surgery.
On many occasions, one line of treatment is not enough. Things such as nasal dilators to open airways, or a device to improve tongue strength can be used as adjuvant therapies.
On many occasions, one line of treatment is not enough."
Patients diagnosed with sleep bruxism are typically provided a mouth guard which do not prevent grinding, as bruxism is a neurological condition, but prevents damage to the dentition and the TMJ. If patients have sleep bruxism due to a restricted airway, a mouth guard can sometimes worsen things, removing space from the tongue, causing it to drop back. It is key to assess the risks of any potential underlying airway disorders and provide a protrusive mouth guard to patients if required to keep the airway patent.
Lifestyle changes, sleep hygiene and weight control are three very important aspects for health in general. However, those with underlying sleep apnoea or snoring are often unsuccessful in managing the condition through lifestyle changes alone and would require further intervention, but weight control is significantly helpful.
How to get appropriate training
Dentists interested in specialising in the discipline of dental sleep medicine can reach out to the British Society of Dental Sleep Medicine (BSDSM) and enrol as a member. Members receive benefits for an annual fee, including a free member’s day each year. The day is invaluable for members, and a chance to learn about the importance of the airway within dentistry, from medical and dental specialists, as well as network with peers and medical colleagues. Webinars are also available, delivered by Board Members with free enrolment for fully paid-up members. Resources such as information leaflets for practices and patients are also available for members on request.
I applaud these dentists who are interested in helping the patient’s overall wellbeing."
The British Academy of Dental Sleep Medicine, has recently launched a Postgraduate Certificate in Dental Sleep Medicine, (PGCert.) the first of its kind available in this country. It offers more advanced courses for dentists looking to train on a formal basis. The Society and Academy recommend dentists undertake initial training from non-industry led courses.
I am currently working with indemnity providers and the College of General Dentistry (CGDent) to ensure protection for those providing this treatment, dentists are required to have appropriate training and CPD as a minimum.
I have personally found the specialism fascinating and hugely rewarding. Improving the quality of life of not just the affected individual, but also the whole family, is very gratifying. It is equally great to see younger dentists taking an interest in the field, to offer patients more holistic therapy.
I applaud these dentists who are interested in helping the patient’s overall wellbeing, over and above teeth and gums. I would like to see all dentists routinely assess the airways for underlying disorders and refer patients where necessary to support people in feeling good, not just looking good. Joining the BSDSM will help you make these network connections.