FAQs about Dental Sleep Medicine*

What Is Dental Sleep Medicine?

Dental Sleep Medicine* is the designated term for those aspects of Dentistry that pertain or relate to consequences of Sleep Disorders within the scope of Dental Practice. It is a branch of Dentistry and is practiced in conjunction with Medical Physicians.

Dental Sleep Medicine* is the accepted term used both by the Canadian Respiratory Journal and within Canadian Undergraduate University settings using text-books under the same designation.

Dentists who offer Dental Sleep Medicine services* must be able to demonstrate sufficient competence in this field - Canadian Respiratory Journal.  2012 Sep-Oct; 19(5): 307–309.

The American Academy of Sleep Medicine is the largest Body of Guidance in Sleep for Physicians in North America. The Equivalent Body in Dentistry is the American Academy of Dental Sleep Medicine. The College of Dental Surgeons of British Columbia (CDSBC) have developed guidelines reflecting many of those recommended by both organizations.

What Does Dental Sleep Medicine Manage?

The area of Dentistry designated as Dental Sleep Medicine* (DSM) as used in Canadian Publications and Authorship, impacts many of us whether we have teeth or not, yet most people know little if anything about it. Some of the most common sleep disorders are airway problems or Sleep Disordered Breathing (SDB) - like Snoring, Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS). 

Sleep Disordered Breathing (SDB) is the number two most commonly reported sleep disorder after insomnia, yet the greater of these in terms of illness and associated diseases.

SDB is known to have a strong association with insomnia, the most commonly reported sleep disorder so clearly Dental Sleep Medicine is something we need to know a little about. This combination is known as COMISA.

COMISA stands for Co-morbid Insomnia and Sleep Apnea, a condition where insomnia and sleep apnea co-occur, leading to worse sleep, daytime function, and overall health outcomes compared to either disorder aloneDentists trained in Dental Sleep Medicine*(DSM) may be able to help, in conjunction with a physician,  those sleep problems related to the upper airway, jaws and oral tissues, they may be soft or hard tissues of the oral region. After all - the upper airway, jaws and oral tissues are all areas that a general dentist faces daily.  In conjunction with a Medical Physician a dentist adequately trained (CDSBC Guidelines) can provide such a service within the scope of accepted dental practice.

Snoring, Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS)?

Dental Sleep Medicine comprises awareness and screening for common sleep disorders and intervention within the scope of dental practice and as outlined in the CDSBC published guidelines in BC.

Heavy snoring is common - but may not be benign.

Loud snoring (due to a partial collapse of the airway while asleep) is not a benign condition. With or without Obstructive Sleep Apnea, it is linked to high blood pressure, heart attack and stroke. It often splits bed-partners up and disrupts both partner’s sleep although often only one is aware of it!

Marriages and relationships may be strained and the partners split into different rooms and this can even sometimes happen with some of the therapies recommended for OSA such as CPAP too.

Heavy snoring is rarely screened for - yet screening for, this and OSA is becoming an expected standard of care in medical and dental practices. All Dentists are to able and expected to provide this screening as outlined by CDSBC guidelines.

When Obstructive Sleep Apnea (OSA) is suspected.

Following screening by a dentist or doctor, Obstructive Sleep Apnea (OSA) may be suspected and communicated with the patient’s Physician - the Physician can then make appropriate requests for testing and diagnosis. 

In Obstructive Sleep Apnea the airway becomes blocked by the patient’s own soft-tissues often causing near suffocation. Each is measured as an “event” which may occur many times per hour in some people.

Obstructive Sleep Apnea (OSA) is a disease of epidemic proportions. It is estimated that 5.4 million Canadians may suffer from it, yet less than 10% have been diagnosed. OSA is a potentially serious disease yet symptoms may be different in different people which may make diagnosis more difficult.

OSA has a very strong evidential association with Heart Attack, High Blood Pressure, Artery Hardening (atherosclerosis) Stroke and Diabetes.

It’s also has a very strong evidential association with problems during Pregnancy such as gestational diabetes, low birth weight babies and pre-eclampsia. It may lead to Depression, Anxiety and Sexual Dysfunction in some people.

By law, within British Columbia only a physician can diagnose OSA. 

Dentists may presently play a role in screening the patient and directing the patient to the physician toward a diagnosis and then back to the dentist for management of the condition under prescription, when appropriate by the dentist trained as per CDSBC guidelines.

Can young, slim, fit men and women have problems too?

There are those people however who don’t fit the stereotype of Obstructive Sleep Apnea and their diagnosis may therefore be missed - they may be young, slim, fit men and women - yet they seem to suffer excessive daytime sleepiness too, along with the other problems that may be associated with OSA. This may relate to Upper Airway Resistance Syndrome (UARS).

UARS

Upper Airway Resistance Syndrome (pronounced U-ARS) is a condition commonly associated with problems similar to OSA ( lack of energy and even sometimes, pain syndromes like fibromyalgia and jaw joint problems -TMD) yet found in slimmer and younger men and women.

Yet because they are in an apparently different group they are often overlooked from screening as many screening tools were developed before UARS was clinically accepted.

Within the Discipline of Dental Sleep Medicine training, the dentist works closely with and under prescription from a physician. Dental Sleep medicine is not recognized as a Specialty in Dentistry but the College have developed Clinical Guidelines for this area of General Dentistry.

What is a Dental (Oral) Appliance?

Dental Sleep Medicine covers oral appliances too. According to the CDSBC, suitable Oral Appliances made by a qualified dentist, under prescription from the patient’s Physician may be an ideal approach to manage Snoring, Obstructive Sleep Apnea (OSA) and UARS.

A prescription is required because the patient’s physician is responsible for screening, testing, diagnosis, follow up of Obstructive Sleep Apnea and the patient’s overall health and outcome.

For some people, Oral Appliance Therapy (OAT) may provide a better alternative than CPAP (Continuous Positive Airway Pressure) as for many, a smaller appliance is far easier to live with than a mask placed over the nose or face and connected to a bedside pump by a hose. Consequently overall compliance and Adherence is generally greater with OAT.

While somewhat inconvenient to some, CPAP has saved millions of lives over the years for those that who can wear them and has provided a mainstay since its introduction in the early 1980s. 

When patients struggle with, or are unable to wear CPAP the dentist may work alongside the patient’s Physician to review alternatives. The Physician will prescribe for this when appropriate.

There are many types and designs of appliance. A Dentist trained in DSM will use different appliances to achieve different goals. Even those people without all of their teeth may be candidates with appropriate treatment planning and treatment.

Oral appliances may be a successful and effective management tool for many people suffering from OSA, Snoring and UARS. Just like CPAP however, not everyone is a candidate.

Over-the-counter Oral Appliances.

In the case of Snoring, the Physician must assess a patient before even a ‘snore guard’ is made and also for over the counter appliances (OTC) and those devices and “treatments” available online - which may without testing, overlook or disguise a potentially serious disease. Such appliances may also damage the teeth and gums. Alas this commercial area is poorly regulated and many claims are unfounded, false or dangerous. 

That is not to say there is no place for them and under certain situations an OTC appliance or temporary appliance may be indicated.

Consent

Consent is the right of all patients, who can only exercise their autonomy when they are aware of the facts, hence, “informed consent.” If a clinician does not provide all appropriate options, they fail to uphold the standard of practice, undermining the patient’s ability to make a fully informed decision about their care and leaving the clinician liable for potential legal or ethical consequences.

How else can Dental Sleep Medicine help?

Dental Sleep Medicine* doesn’t end there however, because a comprehensive understanding of sleep, and its disorders and the effects on the teeth and jaws allows the Dentist trained in DSM to do much more than just make oral appliances.

An adequately trained and experienced dentist can diagnose sleep related dental problems too, such as some headaches, jaw problems, TMD, broken dental work, worn or sensitive teeth, gum recession, nighttime bruxism (tooth grinding), some forms of facial pain and the many other problems which are often related to sleep disorders when within the scope of dentistry. 

How can a dentist trained in Dental Sleep Medicine help me?

A Dentist trained and experienced in Dental Sleep Medicine* may be able to help you and your sleep in many ways such as screening, advice, recommendations and in various practical ways too.

A Dentist trained and experienced* in Dental Sleep Medicine will understand cause and effect, consequences and prevention, management and treatment. They can advise and sometimes offer assistance in other sleep disorders such as insomnia and sleep related movement disorders by referral.

They will work closely with a patient’s general Dentist as well as Sleep specialists. Any general Dentist can obtain training in Dental Sleep Medicine. The CDSBC advise achievement of competence, experience, skill and continued education as a requirement.

A Dentist trained and experienced in Dental Sleep Medicine is trained to recognize signs and symptoms of, and refer to Physician for a diagnosis of RLS (Restless Legs Syndrome), PLMD (Periodic Limb Movement Disorders), narcolepsy, REM Behaviour Disorder (RBD) and a range of circadian rhythm disorders too. They may assist in the management of insomnia, often acting as a resource and referral hub, ( in combination with the patient’s physician).

A Dentist trained in Dental Sleep Medicine may assist in the connection with some pain disorders including facial pain syndromes and temporomandibular dysfunction (TMD) -  in combination with the patient’s physician.

CDSBC guidelines state that “Dental Sleep Medicine,” is not a recognized specialty in Canada.

Children get Sleep Disorders too.

Children suffer from Sleep Disorders which may eventually affect them for their entire lives. Most remain unscreened, undiagnosed and untreated. Many of today’s children with Sleep Disorders are tomorrow’s adults with clinical problems too. Many parents have been told that their children will simply grow out of their problems. Some will - but many won’t.

With weight gain, a more sedentary culture and the other ‘benefits’ that our society provides, OSA is increasing in both our adult and paediatric populations.

Approximately 10% of children snore regularly, 25-40% of children have SDB and about 2-4% of children experience obstructive sleep apnea (OSA).

How does a dentist become trained and qualified in Dental Sleep medicine?

While many weekend courses are available which give out competency certificates, long-term commitment to education in this area is preferred by the CDSBC and North America’s largest Dental Sleep Medicine Organizations, The American Academy of Dental Sleep medicine, The American Academy of Sleep Medicine and The American Board of Craniofacial Dental Sleep Medicine. 

It is recommended by the CDSBC and the American Academy of Dental Sleep Medicine that Dentists who offer therapy for OSA should be able to demonstrate competency in the field and continue to update their knowledge, experience and skills. Dentists can demonstrate this competency by formal training and examination,  it is possible to take full time training, to achieve Fellowships and Diplomas. Such courses are specialized, intensive and often require returning to full-time education at a University. Dental Sleep Medicine is not recognized as a Dental Specialty in Canada.

Position paper by Canadian Dental Sleep Medicine professionals

All dentists are encouraged to screen their patients as a standard of care. We encourage all dentists to develop an understanding of DSM, as indicated by the * Canadian Respiratory Journal and CDSBC guidelines.

Recognized qualifications include, Diplomate Status for The American Academy of Dental Sleep Medicine or The American Board of Craniofacial Dental Sleep Medicine.  DSM is not a recognised Specialty in Canada.

Full time University Fellowships and Master’s qualifications in DSM are available, but not in Canada, despite its recognised importance by many Canadian University teachers. Postgraduate (University) Qualification in Dental Sleep Medicine (DSM) is not available in Canada.

Behavioural Sleep Medicine

Behavioural Sleep Medicine is an expanding area of sleep psychology that focuses on the evaluation and treatment of sleep disorders by addressing behavioural, psychological, and physiological factors that interfere with sleep. For years dentists have successfully promoted health through smoking cessation, weight loss and exercise, oral hygiene and oral cancer checks. As we are faced with the epidemic of Sleep Disordered Breathing it is expected that this area of healthcare (within the dentist’s remit) will be embraced by the dental team. Postgraduate (University) Qualification in Behavioural Sleep Medicine (BSM) is not available in Canada.

Dental Sleep Medicine in British Columbia

While Dental Sleep Medicine is not recognized as a Dental Specialty by the CDSBC it is hoped that dentists will seek recognized qualification and that Canada will offer Postgraduate University training in the future - the University of British Columbia (UBC) lead by Dr. Fernanda R Almeida is an advocate in undergraduate education here in BC. Postgraduate (University) training in Dental Sleep Medicine is not available in Canada.

The American Academy of Dental Sleep Medicine is joined by other groups supporting National Dental Sleep Medicine initiatives, including the British Academy of Dental Sleep Medicine, the Australian Academy of Dental Sleep Medicine, the Irish Society of Dental Sleep Medicine and the European Academy of Dental Sleep medicine, Dental Sleep medicine is presently not supported in Canada.

What about my general health?

With screening, and working with a physician, Dentists adequately trained and experienced in Dental Sleep Medicine may assist you to avoid many systemic and dental diseases using a dental appliance or professional advice. There can be indirect assistance in improving your health, safety and quality of life (in combination with the patient’s physician).

A dentist trained and experienced in Dental Sleep Medicine* can assist in finding alternatives to CPAP when appropriate, ( in combination with the patient’s physician).

They can help stabilize and protect expensive dental work that you have had performed and also to help children to develop optimally. This may minimize or avoid braces.

As a developing discipline, Dental Sleep Medicine may be considered as one of far reaching and significant benefit in general health.

References.

*Position paper by Canadian Dental Sleep Medicine Professionals - Canadian Respiratory Journal. The Canadian Respiratory Journal is a bimonthly peer-reviewed medical journal. It publishes original research and news dealing with respiratory disease, sleep medicine, critical care, and thoracic surgery as well as continuing medical education and practice guidelines.

CDSBC Guidelines.

If you want to find out more about General Sleep - visit www.abettersleep.net