As indicated in Part 1 of this series, snoring is mankind’s most common obnoxious involuntary behavior.  Over age 40, 60% of all men and 40% of all women snore.  The vast majority of them would certainly prefer not to.  However, until the advent of dental anti-snore devices there was not a lot they could do about it.

If you have a snoring problem and visit a physician you will most likely get advice to lose weight, sew a tennis ball to the back of your pajamas to prevent sleeping on your back, or learn to live with it---measures of limited value in mild cases.  If your problem is more severe, your physician may advise you to have your airway surgically enlarged with a UPPP (uvulopalatopharygoplasty), or to be fitted with a CPAP (Continuous Positive Airway Pressure) device.

Besides the usual risks of surgery, the UPPP success rate is less than 50%.  CPAP consists of a compressor that pumps air into the lungs all night via a heavy gauge tube and nose mask harnessed to the head.  Theoretically the CPAP can obtain 100% success in every case by simply turning up the air pressure high enough to blow through any obstruction.  Many patients, however not only dread the idea of being tied to a machine, but for various other reasons will not tolerate the CPAP.

The bottom line to the primary snoring problem: the medical profession has no practical solution for it, but dentistry does.  By primary snoring I mean snoring without the breath stoppage of OSA (obstructive sleep apnea).  The treatments offered by physicians are either of limited benefit or are as great a problem as the original snoring. 

Dentistry offers the only practical solution to one of mankind’s most prevalent problems.  The NAPA (Nocturnal Airway Patency Appliance) eliminates snoring in approximately 80% of the cases; in another 15% of the patients,  it reduces snoring to where it is tolerable to bed partners.  Only in about 5% of the cases do its results not justify wearing it.  The NAPA not only eliminates or reduces snoring in the vast majority of the cases, it is highly efficacious in the treatment of OSA.  Paradoxically,  this effectiveness creates a protocol problem.

The obstructive sleep apnea syndrome is a medical problem, and in most states dentist are not licensed to treat it without a prescription from a physician.  Not all snorers have OSA, but all patients with OSA snore.  Approximately one in ten snorers has an RDI of greater than 15.  An RDI of 15 indicates a mild degree of OSA, and a dentist who treats snoring problems may inadvertently also be treating OSA.  There are some who say that a dentist, therefore should never treat a snoring problem without a prescription from a physician.  I believe this makes about as much sense as requiring a prescription from a physician before making an occlusal splint for a headache patient since the headache could be due to a brain tumor or some other severe malady.

Since about half the adult population snores, sending all snorers to physicians would deluge their waiting rooms with patients for whom they have no treatment.  Also a physician cannot diagnose OSA without polysomnography an overnight sleep test, which costs about $1200.  Only a small percentage of snorers need to be subjected to this test.  The physician would be spending most of their time screening---a procedure that can be done by the dentist during the patient’s first appointment.

Although dentists legally cannot diagnose OSA, they can perform a very valuable service by screening patients, and referring only those suspect of having the OSA syndrome.  There are some who even question the dentist’s qualifications to do this screening.  Although the diagnosis of OSA requires sophisticated and expensive equipment and procedures, screening for OSA is a relatively simple procedure.  The difference between screening and diagnosis is precision.  If one were attempting to screen out 50% of a group he would need a much more sensitive screening instrument than if he were to cull out 10%.  Since the percentage of apneic patients among the snorers is approximately 10%, one can error on the side of caution, and still select 80% who can be treated for primary snoring with no need for referral to a physician.
A protocol must be set up that permits the dentist to: 
1.offer the patient the best possible care,  2. maintain good professional relationships with medical colleagues, and   3. stay within the parameters of the state dental practice act.  I believe the following protocol meets these objectives.

All candidates for a dental anti-snore devise should receive a thorough dental exam including radiographs, and should be required to complete a medical history form.  Careful note should be made of any indication of heart ailments, high blood pressure, respiratory disease and diabetes.  Determine if these conditions are under control, and if any question, call the patients physician.  It is always good practice, and a good practice builder to call a patients physician when in doubt about any medical problem.

The most important daytime symptom of the OSA syndrome is hyper somnolence.  Daytime sleepiness is closely correlated with the RDI.  Dr. Murray Johns of the Epworth Hospital Sleep Disorders Unit in Melbourne, Australia took advantage of this fact when he devised the ESS (Epworth Sleepiness Scale) to differentiate primary snorers from those with OSA.  The ESS is a simple questionnaire measuring the general level of sleepiness. This is a measure of the probability of falling asleep in a variety of situations commonly encountered during a normal day.

Dr. Johns found that the average ESS score for non-snoring controls was 6, and for primary snorers 8.  While patients with severe OSA average 16 on the ESS, the range is from 10 to 23.  I asked Dr. Johns what score did he believe was the first indication for polysomnography.  He told me that 10 would be the first indication, unless there was evidence the patient would frequently stop breathing, toss and turn, choke or struggle for breath while sleeping.  In the later case he would recommend polysomnographic diagnosis even if the ESS score was 8.

Each patient contemplating NAPA therapy must complete the ESS and the Behavior During Sleep Questionnaire.  After filling out these forms the patient is given the IC (Informed Consent) to read and sign.  The IC informs the patient of his/her probability of having OSAS, and what to do about it, The IC indicates that OSAS is a serious sleep/breathing disorder, and that ignoring it may have dire consequences.  You cannot force the patient to see a physician.  You should indicate that you are treating only the snoring problem, but that their answers to the questionnaires suggest that they also have an OSAS problem, and for that they should see their physician.  Notice the IC indicates that the physician may send the patient back for OSAS therapy with the NAPA.  Only a physician can prescribe a NAPA for the treatment of OSAS, but only a dentist can take the records for its construction, deliver or adjust NAPA.  Without the intervention of a physician the dentist must let the patient know that he/she is being treated only for the snoring problem.

It is wise to send a letter to the patient’s physician.  The physician will appreciate that you are willing to work with him/her and may very likely send you more patients.

Carefully study the Questionnaire for Snoring, the Informed Consent and the Suggested Letter to patient’s physician.  They contain important information, some of which is not repeated in the text of this article.

Follow this protocol closely.  I don’t believe there is any more danger for the patient in the NAPA than in other appliance commonly used in dentistry.  However, we live in a very litigious era, and it is wise to practice cautiously.

 

Peter T. George D.D.S.
Ala Moana Building, Suite 520
1441 Kapiolani Boulevard
Honolulu, Hawaii 96814

Phone (808)947-3737

REFERENCES

Lugaresi E., Cirignotta F., Montagna P. “Snoring: Pathogenic, Clinical, and Therapeutic Aspects” In: Kryger M.S., Roth T., Dement W.C., eds. Principles and Practice of Sleep Medicine, Philadelphia, W.B. Saunders, 1989:495.

 Guilleminault, C., Riley, R.W. and Powell, N.B. “Surgical Treatment of Obstructive Sleep Apnea “In: Kryger, M.S., Roth, T., and Dement, W.c. eds. Principles and Practice of Sleep Medicine, Philadelphia, WB Saunders, 1989: 574-576. 

Crowe-McCann, C., Nino-Murcia, G., and Guilleminault, C. and Partinen, M. eds.  Obstructive Sleep Apnea Syndrome: Clinical Research and Treatment, New York, Raven Press, LTD., 1990: 121-123.

 Young, T., Palta, M., Dempsey, J.,Skatrud, J., Weber, S., Badr, S.  “The Occurrence of Sleep Disordered Breathing Among Middle-Aged Adults” In: New England Journal of Medicine 328: 17, 1993 

Westbrook, P.R. “Apnea” In: Carskadon, M.A. ed. Encyclopedia of Sleep and Dreaming, New York, Macmillan, 1993: 49. 

Johns, M.W. “Daytinme Sleepiness, Snoring, and Obstructive Sleep Apnea” In: Chest 103:30-36, 1993 

Johns, M.W. “A New Method for Measuring Daytime Sleepiness: The Epworth Sleepiness Scale” In: Sleep 14 (6): 540-545, 1991 

All candidates for a dental antisnore device should receive a thorough dental exam including radiographs, and should be required to complete a medical history form.