The most important step in establishing a practice in oral appliance therapy for snoring and sleep apnoea is having a simple and efficient method for organising sleep studies for dental patients. In the following article, I answer some of the questions I commonly get asked by dentists.
Q: Is a sleep study the only way to diagnose sleep apnoea?
A: Yes. Although there are many instances in which you can be quite sure that a patient has sleep apnoea based on their report and history, there are other conditions that can mimic the symptoms, and therefore the only way of achieving a definitive diagnosis is with a sleep study.
Sleep physicians are particularly interested in the level of sleep apnoea present as this determines the optimal treatment and how it’s managed. It is not possible to determine the severity of sleep apnoea just from the signs and symptoms.
Q: I understand there are sleep studies that could be done by an overnight stay in hospital, and ones that can be done in the patient’s own home. Which might be best for my dental patient?
A: Traditionally sleep studies have been done by an overnight stay in the hospital with various parameters of sleep measured with sensors, including blood oxygen, airflow, levels of snoring, body position, stage of sleep etc.
In recent years sleep studies are mostly done by the patient taking a diagnostic unit home for use when sleeping. A home sleep study is far more preferred by patients and they get results that replicate their usual sleep. With the advent of technology, home sleep studies are considered very close in accuracy to those done in a hospital setting.
Q: Do we have to do a sleep study on every single patient before making an appliance? What about a patient who only snores, is not tired or sleepy, has no medical problems and is not overweight?
A: If a patient regularly snores then sleep physicians will generally do a sleep study, even if the patient has no other signs or symptoms of sleep apnoea. It is well recognised that there is often not a great correlation between sleep apnoea and signs or symptoms, and it is possible to have a patient who has severe sleep apnoea yet is not particularly tired.
Snoring is a sign of some degree of obstruction, and it is important that a dentist does not proceed with an oral appliance without a sleep study or at least an assessment by a sleep physician.
Q: Often it’s obvious that the patient does have sleep apnoea as they snore loudly, they have been seen to stop breathing and they are quite tired during the day despite getting at least seven hours of sleep. What is the point then of doing a sleep study?
A: It’s true that often it is obvious that the patient does have sleep apnoea. However what’s most important about the sleep study is to know the severity of the sleep apnoea – whether it is mild, moderate or severe. The level of sleep apnoea will determine the best treatment option. It will also determine the potential health consequences of their sleep apnoea and the importance of complying with treatment. If the patient is using an oral appliance the level of severity will determine whether a follow-up sleep study is required while the patient is sleeping with the appliance.
Q: Why has getting a patient diagnosed with sleep apnoea been such a barrier for dentists?
A: For a patient to be able to claim Medicare rebates, a dentist cannot refer them for a sleep study, or refer them directly to a sleep physician. The referral needs to go via a GP. This adds extra steps and complicates the process and you often lose the patient in the system. Most of the time the patient gives up out of frustration or just gets offered the CPAP machine, or told to lose weight by someone who doesn’t understand oral appliances. You’ll be lucky if you see the patient again for their sleep problem.
Q: What is the best method for a dentist to use in diagnosing their patients?
A: We are utilising an extremely efficient and cost effective system in which a diagnostic sleep unit is couriered to the patient’s home. The patient also has a Telehealth consultation with a sleep physician and the results of the sleep study, and the Telehealth consultation, are sent to the dentist.
The results include a diagnosis as well as treatment recommendations, which may include an oral appliance for the majority of patients diagnosed with sleep apnoea.
by Dr Harry Ball
BDSc LDS (Melb) M Counsel. (Lat.) Grad Dip Counsell. & HS (La.)
Past co-chairperson dental sleep medicine council of the Australasian Sleep Association.
Co-Director SleepWise Clinic
For details of the next Dental Sleep Institute training program: “Oral Appliance therapy for Snoring Sleep Apnoea & Bruxism” visit the program page here.