Finding and Treating Sleep Apnea in Your Practice

Part 2 - What to look for when screening patients for sleep apnea

Instructors:

Dr. Kent Smith, DDS

Dr. Kent Smith, DDS

Kent Smith is the course creator and original instructor for Sleep Breathing Disorders at LVI Global, co-founder of the Dental Organization for Sleep Apnea and is on the Medical Advisory Board of Sleep Healers®. He writes and lectures internationally on obstructive sleep apnea and other sleep disorders.

Dr. Smith reviews what to look for in your patients that may have sleep apnea.

So here's some things we look for in our patient, our dental patients that you might not be looking for right now when you're doing your exam. We look for large necks. In male specifically if the neck is 16 inches or larger then we get a little concern. Well really 17 inches. Women 15 inches. Men 17 inches. Men will usually have an idea what their neck size is. Women will not have a clue. So it's really best to just measure them. We look at retrognathia, small recessed chins. We look at overbites which can lead to or predispose somebody to sleep apnea. We look at weight obviously. The BMI the higher it gets the more likely they already have the sleep apnea. Scalloped tongues which indicate three car tongue in a two car garage. There's not enough room for the tongue. We also look at eroded enamel. The enamel gets eroded from GERD from acid reflux. Our patients with sleep apnea one of the signs and symptoms of occluded breathing is eroded enamel from GERD. We also look at enlarged tonsils. Tonsils can be a large part in the diagnosis of sleep apnea the tonsils occlude the airway so we measure the size of the tonsils. It gives us a good indication specifically with kids, all we have to do is remove the tonsil and that fixes their obstructive sleep apnea. Next we look at decrease inter-molar distance. If the palate vaults up and occlude the nasal pharynx, that can be a problem. We look at tongue bars and tongue studs which can occlude the airway. Maxillary splint have been shown to occlude the airway as well as full dentures that aren't worn during the night. So we'll talk a little bit about those. Here's some easy patients to predict. Speaking of neck size the males in this photo have more than a 17 inch size or 17 inches or larger and the females have 15 inches or larger. So you can pick these patients out of your practice and say they probably have some sleep apnea. There are some retrognathic patients if their chin is back, if they have micrognathia or retrognathia it can be occluding the airway. This shows you very well how weight gain can increase the likelihood that somebody has sleep apnea. The average 187-lb person has no sleep apnea. They gained about 20 pounds. They get some moderate apnea at 20.9. At 220, they developed moderate sleep apnea, and at 244 the average 240-lb person has an AHI of 60, very severe sleep apnea. So as you can see, weight has a lot to do with our sleep apneic. Here's our scalloped tongue. You've all seen scalloped tongues. So when you see this I want you to start thinking about sleep apnea. Maybe there's not enough room for the tongue but tongue has to fall back against the back of the airway and occlude it. That stops the breathing. Here's the erosion. It's what erosions looks like. You see this all the time in your practice. Of course you can have GERD and acid reflux without having sleep apnea but if you see this I want you to start thinking about sleep apnea. Here's what a large tonsils look like. You see this. This have come passed the posterior tonsil pillars. Those are the pillars in front and behind the tonsils if they come out passed that they are occluding the airway. So, that's the situation you need to start looking again specifically with kids. Here's some what we called a kissing tonsils. They're completely occluding the airway in additional to the uvula. Start looking in the back of the throat. We call this the uvula shot when we take this photo. I want each of you to start adding this to your, I'm sure most of you take a set of new patient photos. You probably don't take this one. Take this shot. It's called the uvula shot. There's another one. This is what the narrow arch looks like as you know. You'd probably know the story about kids when they have allergies they have a very difficult time breathing through their nose. They have to breathe through their mouth. The tongue doesn't go up in the roof of their mouth. So the buccinators win. They push in the maxilla and squeeze it in. The palate vaults up into the nasal pharynx. It makes an even more difficult to breath through their nose. So these kids develop into obligate mouth breathers over time. It's in my opinion, its child abuse if we don't get our patients breathing through their nose early on in life. Here's a little cotton roll trick. You can just put a cotton roll between the two first molars. If it crimps like that that's an indicator that the palate just isn't wide enough. Maxillary splints. Those of you that make these in your practice I would advise you to rethink that. Maybe consider going through mandibular splints because maxillary Michigan type splints that cover the entire arch and I'm not talking about NTI type splints, but a maxillary full arch splint has been shown to increase sleep apnea. This was a research study done out of respiratory research. It's not a dental magazine. A journal obviously. And they did a study showing what happens when patients leave their dentures in versus taking their dentures out. Now 48% of these patients already have sleep apnea because they're in the older age group but 71% did when they took their dentures out. The AHI actually increase by 58% on removing the dentures during sleep. So I know what you were told in dental school is to have them leave their dentures in, I mean to take their dentures out during sleep. That's a mistake. You need to have them take their dentures out during evening. Let their mouth breath. You don't want fungus to occur. I know all of the issues that they told you in dental school with leaving the dentures in. Have them leave them out for a few hours in the evening but put them back in during sleep and you'll be doing them a favor. Here's some not so obvious patients. I'm treating every one of these patients for sleep apnea. You wouldn't know that by looking at them. That's why it's very important to screen every patient in your practice. This lady in the upper right this is her airway here on the lower right. That is her airway. The normal airway is in the upper left. That's what it should look like. So until you take this uvula shot, you don't know what their airway looks like. This is how we screen our patients. It's called the Epworth sleepiness scale. We give this to every new patient. They fill it out with their new patient paperwork. And if nothing else it just gives us something to discuss. If they end up being very sleepy, we want to find out why. Is it related to sleep apnea? Now just because they're sleepy doesn't mean they have sleep apnea. But it is one of the indicators and it's something that we can use to have that discussion with our patients. Here's another way you can examine your patients. It's called the cricomental space and it's a good way without a sleep study to sort of prescreen your patients. If they're cricomental space, there's this turkey waddle right here. It's right here. If that's less than 1.5 cm, I'm going to show you a graphic in a second how we look at that. If the pharyngeal grade is greater than 2 and if they have an overbite, 95% of the time they have sleep apnea. So it's a really good screening technique. This is the turkey waddle. You draw an invisible line kind of mentally from the inner mentum to the cricoid cartilage. Sorry. You just draw a dotted line and then you bisect that and go to the nape of the neck. If that's less than 1.5 cm, there's a good chance they have sleep apnea. They fall into our formula okay. So you don't want to see a big turkey waddle here. Here's how we measure it. We look at them from the side. As you can see neither of these patients has any cricomental space. It's gone. They had a large turkey waddle. She has a large cricomental space. She's missing some other things mentally but at least she has a large cricomental space.