Obstructive sleep apnea (OSA) has a global prevalence of 9-38%, with cases in the United States estimated at around 54 million. Surprisingly, about 80% of OSA cases remain undiagnosed. OSA is considered a sleep-related breathing disorder that accounts for obstruction of the upper airway, causing apneas. In addition, the obstruction caused by OSA leads to intermediate effects such as sleep fragmentation, heart rate fluctuations, hypoxia, among others.
The prevalence of OSA is higher among African Americans, Native Americans and Hispanics. Literature demonstrates racial disparities in presentation, prevalence, diagnosis, risk factors and OSA treatment. Typically, moderate to severe OSA cases occur in one-fifth of middle-aged men and one-tenth of middle-aged women. Nevertheless, according to the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), Puerto Rican women have the highest sleep apnea prevalence. In contrast, Puerto Rican men have the lowest.
Comorbidities associated with OSA include substance abuse, alcohol use, tobacco, decreased productivity, stress and accidents. These resulted in costs averaging $150 billion to the United States in 2015. Mental health, cardiovascular disorders, metabolic diseases, diabetes, renal diseases and cancer are all associated with OSA. The manifestations of OSA include bed partner disturbance, mood disorders, daytime sleepiness, fatigue, insomnia and hypersomnolence, with symptoms ranging from snoring or apnea episodes to cardiovascular consequences. Additionally, tongue size and soft-tissue features (hyoid position) are OSA risk factors, as well as pulmonary dysfunction, genetics and obesity. These factors may all be present for years before diagnosing OSA.
Diagnosis of OSA starts with considering the patient’s medical history, followed by Epworth Sleepiness Scale and a home sleep apnea test administration. The gold standard remains the overnight polysomnography. The Apnea-Hypopnea Index (AHI) is the polysomnographic parameter used by the American Association of Sleep Medicine to categorize mild (5-15 AHI), moderate (15-20 AHI), and severe (>30 AHI) cases of OSA. While the dental practitioner can screen for OSA symptoms or risk factors, a sleep medicine physician is the one who gives an accurate diagnosis.
Current treatment for OSA involves continuous positive airway pressure (CPAP) as first-line treatment and oral appliance therapy (OAT). Notwithstanding, patients prefer OATs, and studies show that less than half of patients tolerate CPAP. Therefore, the FDA has approved the use of OATs for mild to moderate cases of OSA.
OATs are customarily fabricated by a dentist. Their function is protrusion and stabilizing the mandible to achieve and maintain a patent upper airway during sleep. There are different categories of OATs, but mandibular advancement devices (MADs) are primarily used in clinical practice and are prescribed alone. An advantage of MADs is that they reduce AHI, with approximately one-third of patients showing complete OSA resolution and an AHI less than five under this therapy. Still, studies have shown comparable health outcomes when choosing between CPAP and MAD treatments.
Moreover, a poll on dental sleep medicine done by the National Dental Practice-Based Research Network (PBRN) in February 2021 demonstrated that dental practitioners face challenges when it comes to screening and treatment of OSA. But at the same time, the National Dental PBRNs poll gave insight into the growing interest among dental practitioners taking courses in dental sleep medicine. However, OATs have several issues, including payors eligibility and the bridge communication between physicians and dental sleep medicine specialists. Nonetheless, the field of treatment for OSA is exponentially evolving, with more dentists getting qualified to participate and provide care to these patients.
~Yasmarie Santana-Rivera, Puerto Rico ’24, Electronic Editor (with assistance from Dr. Maria Therese Galang-Boquiren, University of Illinois-Chicago, and Dr. Rahma Mungia, University of Texas Health Science Center)