April 2014

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Obstructive sleep apnea (OSA) affects approximately 18 million people in the United States, and is the most common form of sleep-disordered breathing.1 It is also associated with life-threatening conditions, such as stroke, hypertension and congestive heart failure.1 Two dental hygiene educators explain to Sunstar E-Brief why OSA falls within oral health professionals' scope of practice, and address the importance of early detection.

As the oral cavity is often referred to as the "gateway to the body," dental hygienists have good reason to develop expertise in handling patients affected by OSA.

"OSA is a serious, life-threatening condition that often goes undiagnosed for years," says Diane Kandray, RDH, MEd, an associate professor in the Dr. Madeleine Haggerty Dental Hygiene Program at Youngstown State University in Ohio.

According to Kandray, dental hygienists can recognize traits, characteristics and behaviors that predispose patients to a variety of systemic conditions and diseases, including sleep disorders. "Dental hygienists who are aware of the signs and symptoms of OSA can screen patients during routine appointments and refer them for further evaluation," Kandray asserts.

Oral manifestations of OSA are sometimes interpreted as common anomalies, explains Tammy Swecker, BSDH, MEd, RDH—an associate professor in the Department of Oral Health Promotion and Community Outreach at the Virginia Commonwealth University School of Dentistry in Richmond. She cites a patient with oral signs of gastroesophageal reflux disease who also grinds his or her teeth as an example. "This patient may be misdiagnosed if screening for OSA isn't completed during a recare appointment," she says. "In this case, the dental practitioner may recommend a nightguard when the patient actually needs a referral to a sleep physician for a sleep study and definitive diagnosis."


OSA occurs when throat muscles relax intermittently during sleep and block the airway. Men who are middle-aged and overweight are at greatest risk for the condition.2 Smoking and alcohol consumption are additional risk factors.3-5 In addition to habitual loud snoring, daytime fatigue and sleepiness are also clinical indicators of OSA.6 Early detection of OSA is vital because interventions may decrease the risk of other systemic diseases and improve quality of life.7

Swecker explains that proper screening for OSA begins with a thorough analysis of the patient's medical history, followed by an extraoral and intraoral examination. During the intraoral examination, she notes, patients should be screened using the Friedman Tongue Classification System (Figure 1).8

Figure 1. The Friedman Tongue Classification System is used to assess the tongue's position in the mouth and assigns a value to each position based on how much the tongue obstructs the airway.8

"If the tongue classification and/or shape signify the tongue is blocking the airway, the practitioner should initiate a dialogue about the patient's sleep habits," Swecker says.


Once a sleep disorder is diagnosed, Kandray says, dental professionals should be aware of the treatment option chosen by the patient. A continuous positive airway pressure (CPAP) machine is often prescribed for patients with OSA. The device keeps the airway open by providing air through tubing connected to a mask worn while sleeping.

During maintenance visits, dental hygienists should document patients' compliance with CPAP devices, Swecker says. She points out that many patients do not like to wear CPAP masks because their use can dry out the mouth and airway, and cause discomfort and nosebleeds. CPAP machines can also be noisy and cumbersome.

"If a patient is noncompliant with the CPAP, then an oral appliance can be fabricated by a dentist or a dental lab technician," Swecker says. "Dental hygienists need to document compliance with appliances prescribed for the treatment of OSA, while maintaining an ongoing dialogue with the referring dentist and sleep specialist."


Patients who do not respond to CPAP therapy may turn to other treatment options, such as oral appliance therapy or, in extreme cases, surgery. In a case study by Doff et al,9 a 32-year-old morbidly obese woman with severe OSA was initially fitted with an oral appliance that positioned her mandible in a protruded and downward position. The mandible was set at 88% of the patient's maximum protrusion—effectively holding open the airway during sleep. Despite improvements in the number of subsequent apneas (cessation of airflow for at least 10 seconds) and hypopneas (decrease in airflow occurring during sleep), the woman's OSA persisted. As a result, maxillomandibular advancement surgery, genioplasty (chin surgery) and cervicomental liposuction were performed. The procedures completely resolved the patient's OSA.9

Untreated OSA can have significant health consequences—from oral health problems, like bruxism, to life-threatening health issues, such as cardiovascular disease. In addition, sleep deprivation caused by OSA can have dire results, such as increased risk of motor vehicle accidents.10 Early detection of this disorder can support successful intervention and improve patients' overall health and quality of life. Dental hygienists are well suited to screen for OSA and to ensure that at-risk patients receive appropriate referrals so they get the treatment they need.

  1. Barsh LI. The recognition and management of sleep–breathing disorders: A mandate for dentistry. Sleep Breath. 2009;13:1–2.
  2. Mayo Clinic. Obstructive Sleep Apnea. Available at: mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/basics/definition/con-20027941. Accessed April 7, 2014.
  3. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291:2013–2016.
  4. Koutsourelakis I, Vagiakis E, Roussos C, Zakynthinos S. Obstructive sleep apnea and oral breathing in patients free of nasal obstruction. Eur Respir J. 2006;28:1222–1228.
  5. Ekici M, Ekici A, Keles H, et al. Risk factors and correlates of snoring and observed apnea. Sleep Med. 2008;9:290–296.
  6. Ward Flemons W, McNicholas WT. Clinical prediction of the sleep apnea syndrome. Sleep Med Rev. 1997;1:19–32.
  7. Kelly S, Waite P. The role of the general dentist in the management of obstructive sleep apnea, application of oral appliance therapy, and the indication for surgery. Gen Dent. 2013;61:30–37.
  8. Friedman M, Hamilton C, Samuelson C, Lundgren M, Pott T. Diagnostic value of the Friedman Tongue Position and Mallampati Classification for obstructive sleep apnea: a meta-analysis. Otolaryngol Head Neck Surg. 2013;148:540–547.
  9. Doff MHJ, Jansma J, Schepers RH, Hoekema A. Maxillomandibular advancement surgery as alternative to continuous positive airway pressure in morbidly severe obstructive sleep apnea: a case report. Cranio. 2013;31:246–251.
  10. Centers for Disease Control and Prevention. Insufficient Sleep Is a Public Health Epidemic. Available at: cdc.gov/features/dssleep/. Accessed April 7, 2014.

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