Resting Easy
Some dentists find they can do their part to help patients get a good night’s sleep.
How much sleep do we really need? That may vary from one individual to the next, but the bottom line is, we all need enough sleep to function well the next day. Unfortunately for many, that doesn’t happen. Obstructive sleep apnea is a common sleep disorder that affects as many as 20 million Americans. Today, not only are physicians taking a greater interest in their patients’ sleep patterns, so too are some dentists.
"We are the first line of defense," says Steve Poss, DDS, who owns a Brentwood, Tenn., practice. "As dentists, we can play a critical role in sleep apnea and sleep disorders. I have treated a lot of teeth grinding issues and sore jaws, and [these symptoms] often are associated with sleep apnea. I have had patients fall asleep in the chair while I’m talking to them, because they don’t get enough sleep," he adds. "Imagine a truck driver doing something like that."
Obstructive sleep apnea
Obstructive sleep apnea (OSA) occurs when an individual’s airway temporarily collapses during sleep, preventing or restricting breathing for as long as 10 seconds. Normal breathing typically resumes with a snort or choking sound. Generally, those afflicted with obstructive sleep apnea have an airway that is narrower than normal at the base of the tongue and palate. When lying flat, the palate rests above the air passage. When the pharyngeal muscles relax, the palate can fall backwards, obstructing the airway.
Several other causes can trigger OSA, including the following:
- A deviated septum (the middle wall of the nose separating the two nostrils) narrows the nasal air passages.
- Filters in the nose, called turbinate’s, obstruct airflow when they become swollen.
- The back of the tongue falls backwards, obstructing breathing.
- The side walls of the throat fall together, narrowing or closing the airway.
- A thick neck circumference greater than 16.5 inches may narrow the airway.
- Obesity or excess weight can be a factor, particularly when fat deposits around the upper airway obstruct breathing.
Symptoms and risks
Although patients with obstructive sleep apnea may experience disrupted sleep three or more nights each week, they generally do not report awakening during the middle of the night. Often, they merely move from a deep sleep stage to a shallower level of sleep. But, disrupted sleep can leave patients groggy during the day, interfering with their ability to concentrate and possibly leading to accidents. Other common symptoms include insomnia, fatigue, irritability, headaches and poor memory and attention.
The cessation of breathing every one to four minutes during the night can cause increased stress on the heart, placing patients at risk for certain medical complications, such as high blood pressure, heart failure, heart rhythm disturbances, atherosclerotic heart disease, pulmonary hypertension and insulin resistance. In addition, the risk for congestive heart failure reportedly increases by 2.3 times, and the risk for stroke is said to increase by 1.5 times with sleep apnea. Finally, obstructive sleep apnea increases patients’ risk of sudden death or injury (if grogginess occurs while driving, working, etc.).
Treatment
There are several treatments available for mild to moderate obstructive sleep apnea. Obese patients are encouraged to lose weight, and for mild OSA, this sometimes is enough to alleviate the problem. In other cases, having the patient change his or her sleep position and avoid sleeping on the back can help as well. Other treatments include:
- Continuous positive airway pressure (CPAP). The patient wears a mask over his or her nose during sleep, which increases the air pressure inside the throat, preventing the throat from collapsing during sleep. The mask also helps eliminate snoring, gasping and choking during sleep.
- Oral appliances. A dentist fits the patient with an oral device, similar to a retainer or sport mouth-guard. The device is designed to keep the jaw and/or tongue in a forward position, enabling the airway to remain open.
- Surgery. In some cases, the physician may recommend surgery to reconfigure the patient’s upper airway to help it remain open during sleep.
Home sleep test
Until recently, patients suspected of having a sleep disorder generally have been referred to sleep labs and hospitals for an overnight polysomnogram. While these tests are widely supported by specialists, the process can be costly and/or inconvenient for patients. Today, however, dentists and physicians have another test at their disposal. Since 2004, the Watermark Medical ARES™ Home Sleep Test has been FDA-approved for overnight use in patients’ homes. The home test is lower cost and more convenient for patients compared with checking into a hospital or laboratory, according to the manufacturer. And, for healthcare providers – dentists included – it offers an opportunity to provide good patient care while keeping revenue in-house.
What it is
A Type II device, the ARES is approved by Medicare and many insurance companies. Dentists and physicians can screen patients for sleep abnormalities during their routine oral or health checkups. When abnormalities are found, the dentist or physician may prescribe the portable monitor, which records as many as 10 channels of the patient’s physiological data from the forehead, including the following:
- Electroencephalogram (EEG), a test that measures and records the electrical activity of the brain.
- Electro-oculography (EOG), a technique for measuring the resting position of the patient’s retina.
- Electromyogram (EMG), a technique for evaluating and recording the electrical activity produced by skeletal muscles.
- Echocardiogram (ECG), which measures heart rate and airflow.
- Respiratory effort and blood oxygen saturation (SpO2).
- Snoring levels, using a calibrated acoustic microphone.
- Head movement and position, using accelerometers.
- Pulse rate.
- Venous volume.
Patients wear the sleep test device on their forehead when they go to sleep at night. The device generally is worn for one night but is designed to capture and store data for up to three nights of sleep. The EEG, EOG and EMG functions enable the patient’s physician to determine how much rapid eye movement (REM), deep or light sleep patients achieve throughout the night. Although dentists cannot diagnose sleep apnea, they may send the patient’s data to an ARES physician who will read the test result for $65, according to Poss.
Poss purchased his ARES Home Sleep Test last November for just under $5,000 ($5,400 with add-ons). However, the test is reimbursable and, at press time, having prescribed 15 or 20 tests, his device was almost paid for. Many dentists may not completely understand how reimbursement works, notes Poss. The process can be complicated, since the ARES is only reimbursable on the medical side, he points out. "And about 50 percent of insurance companies still do not recognize it as a diagnostic tool," he says. "But this should change in the next year." On average, Poss is reimbursed 80 percent to 85 percent for in-network patients and 65 percent to 70 percent for out-of-network patients.
Even better, Poss believes the ARES home sleep test enables him to provide better patient care. "If a patient has already had a sleep test, that’s great," he says. "If not, and [his or her] insurance company recognizes the ARES test, I can send them home with it. Even when a patient stops snoring, he may still have sleep apnea," not to mention the many health risks sleep disorders are associated with, he adds. "The test helps me do my job."
The gold standard for treating obstructive sleep apnea is a CPAP, according to Poss. "But, 80 percent of my patients who come to me for sleep apnea are CPAP-intolerant," he says. "The masks can be very uncomfortable. For these patients, an oral appliance is a good alternative. If a patient has moderate-to-severe obstructive sleep apnea, I have an obligation to recommend a CPAP. If the patient says he can’t tolerate it, I have him sign an affidavit and then I make him an oral device."
Cloud computing
The ARES platform is compatible with an Internet-based computer technology called cloud computing, which has attracted the interest of such organizations as Amazon, Google, Microsoft and CA-Computer Associates. Supporters tout two major advantages to hosting data on cloud:
- Security. Data is stored through large party providers, such as Microsoft, Amazon or Google, affording the client a greater level of security and protection.
- Accessibility. With Internet connectivity, data is accessible anywhere at any time, giving users greater flexibility without the need for secure connections. It also reduces disaster recovery/business continuity requirements.
Proponents of cloud computing believe that for the medical and dental communities, the technology will facilitate shared resources, software and information. This means that physicians and dentists will have access to mutable (updated) data to more patients. Supporters cite other
advantages as well, including:
- Increased access for consumers to diagnostic testing.
- Lower costs to physicians and patients.
- Increased accuracy in tracking the long-term health and wellness of the patient.
How to sell
Because the ARES test is still relatively new to the market, sales reps will have to educate their dental customers. Some good leading questions are:
- "Doctor, how are you currently addressing your patients who complain of daytime sleepiness and snoring?"
- "Do you notice that some of your patients have inflammation at the back of their throat?"
- "Do a number of your patients appear to have a large neck and waist size (17-inch neck and 40-inch waist or greater for men; 16-inch neck and 36-inch waist or greater for women)?"
- "Are a good number of your patients obese, or are you aware that they have diabetes, hypertension and heart disease?"
Reps should also inform their customers that the home sleep test provides data in a two-page report that is interpreted by a board-certified sleep physician. And, Watermark Medical can help connect dentists with local sleep specialists to help manage patients who are more difficult to diagnose.
At the end of the day, dentists such as Poss believe that your dental customers will be able to rest easy that they are providing the best level of care – as well as a better night’s sleep – for their patients.
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