Context

Sleep-related Breathing Disorders (SRBD) affect millions of people of all ages worldwide. They can be the cause of a wide range of physical, dental and mental health problems, ranging from simple day-time sleepiness to life-threatening cardiovascular complications. In addition, SRBDs can increase the risk of psychological problems, including depression and drug dependency, which can damage their social relations and adversely affect their on-the-job performance. Therefore, SRBDs can affect quality of life and have very serious socio-economic consequences including employment loss and traffic accidents.

Scope

This Policy Statement aims to highlight the important role of dentists in prevention, early screening and treatment of young or adult patients with SRBDs by establishing effective inter-professional collaboration with medical sleep doctors.

Definitions

Sleep-related Breathing Disorders (SRBD): disturbance of the normal breathing pattern during sleep.

The most common types of SRBDs are: snoring, Upper Airway Resistance Syndrome (UARS) and Obstructive Sleep Apnea (OSA). They occur when a person's airway repeatedly becomes blocked during sleep despite efforts to breathe. The posterior section of the tongue falls back against the throat and airflow is interrupted. This results in loud snoring and pauses in breathing while asleep resulting a change from deeper sleep stage to a lighter stage even sometimes with episodes of waking up at night, feeling short of breath or gasping for air.

Mandibular Advancement Device (MAD): a therapeutic oral appliance designed to place the mandible, during sleep, in a forward position, keeping the tongue from closing the airway and allowing the patient to breathe more easily. MADs, used in mild to moderate OSA cases, are easier and more comfortable to use than the Continuous Positive Airway Pressure (CPAP) appliances. Therefore, the patient’s compliance rate is believed to be higher with MAD than with CPAP appliances. CPAP appliances are used in moderate to severe cases, but MADs should be tried even in severe OSA when the patient is non-compliant to CPAP, Surgery could in certain cases be applied but limited to careful patients selection and special indications.

Principles

After a careful screening has been performed by either or both a medical sleep doctor and a dentist (consistent with local licensure requirements), a treatment plan can be established and the appropriate appliance is decided accordingly.

Policy

FDI recommends:

• universities and national dental associations to provide students and dentists with basic knowledge regarding the important role of dentistry in preventing and treating SRBD, in particular early detection in children and prevention of late onset forms. This can include immediate management as well;   
• all dental and medical health forms to include questions about the patient’s sleep quality and related data to do the screening of SRBDs;
• dentists to provide proper information to patients to understand the process of screening, treatment options and the role of the care providers involved;
• a detailed comprehensive medical, functional and dental screening and an individually tailored treatment plan are necessary to treat patients with an appropriate MAD;
• dentists to maintain regular communications with the medical sleep doctor for a more patient-focused, efficient and positive result;
• treatments to be subjectively and objectively evaluated for efficacy. In case of unsuccessful treatment, all etiological and diagnostic factors should be carefully re-evaluated and the appliance should be re-adjusted. If the treatment is still not satisfactory, the patient should be referred for other means of treatment;  
• dentists to have the training to treat SRBD patients within the ethical limits of their profession in collaboration with the medical sleep doctor involved for successful treatment outcome and higher patient satisfaction.

Disclaimer

The information in this policy statement was based on the best scientific evidence available at the time. It may be interpreted to reflect prevailing cultural sensitivities and socio-economic constraints.

References

1. Gelb ML. Airway centric TMJ philosophy. J Calif Dent Assoc. 2014;42(8):551-562.
2. Obstructive sleep apnea. American Academy of Sleep Medicine. 2008. http://www.aasmnet.org/resources/factsheets/sleepapnea.pdf. Accessed November 5, 2015.
3. Definition of an Effective Oral Appliance. Journal of Dental Sleep Medicine. March 22, 2013
4. Domingo C, Vigil L. Effectiveness of unattended ambulatory sleep studies for the diagnosis and treatment of OSAS. J Eval Clin Pract. 2011;17(1):26-31.
5. G Ital Med Lav Ergon 2014 Jan-Mar;36(1):17-21. (Giornale Italiano di Medicina del Lavoro e di Ergonomia) : “Sleep Apnea, CPAP therapy and work activity” (Article in Italian)
6. Balbi B, Carlo S, Crevacore M, Godio M, Danioni A, Sacco C, Braghiroli A.
7. Minerva Stomatologica 2015 April;64(2):97-109 language: English, Italian: Obstructive sleep apnea syndrome: a literature review Maspero C,.Giannini L., Galbiati G., Rosso G., ferronato G.

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