Author: Michael Kelley
Living with OSA sometimes requires a sense of humor
Every major entertainment medium over the years has taken a shot at the snoring sufferer. Who hasn’t seen the movie scenes of grandpa snoring on the couch after dinner. Or the print ad of the two old guys asleep in their chairs at the club head thrown back with their mouths wide open snoring away. The jokes about how snoring and sleep apnea affect marital relations are so numerous it is impossible to pick just one as an example. This condition is well known as a cause of embarrassment. It is in part due to its prevalence, considered more common than sinusitis. Or perhaps that most sufferers have resigned themselves to a life of sleeping in the back bedroom. One in three people suffer from sleep disordered breathing. The co morbidities are well known, obesity, diabetes and heart disease. All serious conditions requiring a serious response. Where humor can be useful is when the we need to attract attention to educate and inform patients and their loved ones.San Francisco internist Dr Zubin Damania is known as as ZDogg a speaker who writes, performs, and produces award-winning medical rap videos that educate and entertain. The power to entertain and educate is a gift and Dr Damania is excellent he can be reached through his website www.zdoggmd.com for medical entertainment that is slightly funnier than placebo.
Sleepiness as a Measure of Quality of Life
The vocabulary of life quality “Pep”, “Vigor”and “Energy” are inseparable from a discussion of sleep quality. Dr Richard Drake recently published this article which examines “tired” as a key indicator of a potentially deeper and more important condition, Obstructive Sleep Apnea. “Tired and fatigued don’t always mean sleepy. If you had to choose just one word that best describes you most of the time, what would it be? One word. One thing. If you could fix THAT, what would it be? I am a dentist, and I have devoted the last fourteen years of my life to treating the snoring and sleep apnea patients of the world with Mandibular Repositioning Devices. My patients usually describe themselves as sleepy, but in the same breath, many of them also say they are fatigued and tired. Do you snore? Are you sleepy? Have you had a sleep test to look at whether or not your airway is closing down at night while you sleep? If not, then I would suggest you start the process immediately to get a test done. You don’t have to go to a sleep lab to get this done; many patients now do sleep testing in the comfort of their own home, just hooking up a couple of wires.” Evaluation of sleep quality as a measure of quality of life is really important and should not be overlooked. Naturally there are other conditions that will affect sleep quality. Sleep Hygiene, Vitamin D deficiency and thyroid problems. Key to separating these these issues and receiving treatment is to see a trained sleep professional. Click here for complete article
Smoking has Long Term Consequences
There may be 35 million older Americans with undiagnosed lung disease due to cigarette smoking, a new study suggests. They don’t meet the criteria for a diagnosis of chronic obstructive pulmonary disease (COPD), but they still suffer significant lung disease and impairment, the researchers report in JAMA Internal Medicine. “We think we can increase their quality of life by treating them before they get worse,” said Dr. James Crapo, the study’s senior author from National Jewish Health in Denver. Currently, about half of U.S. residents age 49 and older are current or former cigarette smokers, the researchers write. About one in five U.S. adults currently smoke. COPD, the third leading cause of death in the U.S., is often related to smoking, they add. The disease worsens with age and makes it more and more difficult to breathe. Typically, the condition is diagnosed through spirometry, which measures lung function. But Crapo points out that lung function can be impaired to lesser degrees before people qualify for a COPD diagnosis. For the new study, the researchers looked at data from people across the U.S. that had been gathered through spirometry, CT imaging scans of the chest, a walking test and questionnaires. The researchers compared 4,388 people with normal spirometry tests to 794 people with mild COPD and 108 people who never smoked. Overall, about 54 percent of people who had normal spirometry scores had signs of lung disease or impairment, the researchers found. “I think to say they don’t have the disease is wrong,” Crapo said. Compared to the never smokers, those with normal spirometry but impaired lung function had worse quality of life scores, more trouble walking and evidence of airway thickening and emphysema on their CT scans. Click for the complete article
EMG testing as part of Bruxism diagnosis and treatment
A few weeks ago I was asked a very simple question ” Why does dentistry focus so much on tooth wear instead of seeking to identify and treat Bruxism as a disease?”. This question lead to a very spirited discussion. I had just completed a talk where I demonstrated Nox T3’s electromyographic (EMG) leads for testing muscle activity during clenching and grinding while asleep. This is accomplished with an electrode on the masseter and one on the zygomatic arch with a ground behind the ear. The Noxturnal software scores these electrical signals and presents an easy to read Bruxism report. As usual in this discussion I mentioned the research paper by Gagnon et al “Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study”. This study is widely quoted and presents the notion that, an occlusal splint when made for a patient suffering from sleep disordered breathing may actually aggravate the patients existing condition. It is not hard to imagine that this group of Drs. who have made occlusal splints for their patients for their entire careers were interested to discover that there is a whole range of unconsidered elements to this practice. Dr Gordon Christensen in January of 2014 released an excellent video where he suggested EMG testing as a next step for patients with tooth wear before a restorative treatment plan is adopted. click here for the full article
A Time Capsule from the Early Days of Dental Sleep Medicine
Dr L. Wayne Halstrom from Vancouver Canada is a pioneer of dental sleep medicine. Dr Halstrom holds several patents for appliances, bite registration techniques and treatment methodology. His vast experience in the field set the stage for many of today’s standards of practice. Recently Dr Halstrom puled the following video reel from the mid 1990″s out of the vault and made it available for viewing. It struck me that the description of the patients need is really no different today than at the time of these videos. Some of the technologies are comically outdated. We are all very comfortable at the ASBA with the amount of work left to do after 20 years of effort by other organizations in the field. The ASBA is focused on making access to care easier and much more standardized. It is just unacceptable after 20 years to have the care a patient receives to be related to where the patient received their diagnosis. It is widely reported in the literature and the media that there are some 13-18 million Americans suffering with sleep apnea. It is time to develop a standard training program for medical and dental teams to work togather and treat these patients. The American Sleep And Breathing Academy is the place for this training.
Acid Reflux Disease and its Connection to OSA
Dr Jordan Stern in his recent article examines the impact of Acid Reflux on the ability of patients with OSA achieving and maintaining sleep. This is a very serious condition and presents in different ways for different patients. Stomach acid can eat away at the enamel on your teeth,” says Dr. Mark Castle, DDS, an ASBA Diplomate. “Your dentist may be the first to notice symptoms of the disease when he or she detects enamel loss.” A refferal to a sleep specialist or a gastroenterologist for further investigation is often indicated Dr Stern describes the condition as: “Laryngo-pharyngeal reflux (LPR) can result in sleep disturbances by causing frightening awakenings every time a reflux episode occurs. These are frequently manifested by coughing fits and gasping for air in the middle of sleep. The underlying mechanism of apnea is likely laryngospasm from either acid or non-acidic reflux which causes an immediate closure of the true vocal folds (the “vocal cords”) and apnea. Sleep labs, and home sleep studies rarely monitor reflux episodes. Adding a nighttime reflux monitoring system to a home or lab sleep study would require a monitoring system that senses reflux episodes not only in the lower esophagus, but also at the level of the pharynx. Very few laboratories are equipped for this type of testing, and few patients are willing to undergo polysomnography, much less polysomnography with a tube in the nose!” “Foods that help you sleep? There’s no magic. Even if some foods have substances in them such as melatonin that can help us fall asleep, we would have to eat so much (cherries for example – very bad for reflux) that the side effects of eating so much of the foods would be far worse for sleep problems. Chamomile (an herbal drink), or a warm glass of low fat milk (as long as you can tolerate milk and lactose), as part of your bedtime routine can be helpful. The BlueSleep® dietary recommendations: “low fat, low acid, low caffeine, low alcohol”, for reflux are described by Dr. Stern and his co-authors Dr. Jamie Koufman and Chef Marc Bauer in their New York Times Best Seller: ‘Dropping Acid: the Reflux Diet Cookbook and Cure” available at Amazon.” Click here for the full Article
Education Key to Navigating Dental Sleep Medicine
Dr Erin Elliot co President of the American Sleep And Breathing Academy recently published an article that captured the essence of what the academy is trying to achieve. That is an ongoing and continuous educational experience for medical and dental teams trying to work together to provide care for their patients. Dental Sleep Medicine has been an area of dental practice for over 20 years. Dr Elliott reviews, in her article, the questions that each practitioner should ask before signing up for a DSM seminar. “How can you choose? Some of the questions I would ask are: Who is sponsoring it? What is the curriculum? Who is teaching it? How much is it? Do I need to buy “stuff” before I make my tuition back? Do they teach medical insurance billing? How much time/ CE credits do they offer? Is two days really enough?” Key to the educational experience is the ongoing connection with practitioners who are learning right alongside you. Of course each practice is different, however the goals and aspirations of the dental team are the same. This is really the key to the ASBA experience “The American Sleep and Breathing Academy has an annual conference in Scottsdale that is multi-disciplinary. I think these conferences are a great way to learn from the medical side and learn the dental side in a very unbiased fashion. Learning to work side by side with sleep physicians and seeing how to navigate the medical world is imperative to treating sleep apnea in your practice. I like to say, “It is time to put the handpiece down and put the stethoscope on.” We, as dentists, are providing a dental solution to a medical problem. There is no class available teaching you how to interact with your medical community but it can begin as a simple lunch-n-learn or an observation at a sleep lab.” For the complete article click: Article
EU’s Approach to CPAP Compliance. “Use it or Lose it” (Your Drivers License)
Effective January of 2016 all drivers within the European Union when moderate or severe sleep apnea is suspected, will be referred for further medical advice before a driving license is issued or renewed. [1] Drivers currently under treatment for sleep apnea will require a medical review at least every three years for auto drivers (group 1) and every year for commercial drivers (group 2). What this new EU legislation will mean in practical effect is an OSA patient not demonstrating CPAP compliance could lose their driver’s license. Currently all drivers in EU member nations are required to report certain medical conditions to the Driving License Authority. This directive makes OSA a reportable condition. One of the fears is that this may force patients with OSA “underground”. This fear may be valid from experiences with commercial trucking here in the US prior to 2008 when the Americans with Disabilities Act was amended. This provided job protection for commercial drivers with sleep apnea who were under current and effective treatment. The FAA also found issues with air traffic controllers and sleep apnea. Prior to 2010 changes in Aeromedical Medical Exam procedures for air traffic controllers there was no path to certification for a controller diagnosed with sleep apnea. The FAA noted less than .1% of controllers reported having OSA when from studies of the general population it would be expected that about 10% of controllers should. Anecdotal reports of “John Smith” and “Dick Tracy” getting sleep studies done as cash fee for services patients, and sleep tech conversations leading them to believe the patient worked at the airport were common prior to 2010 when the FAA implemented new fatigue management programs which included treatment options for sleep apnea while letting controllers keep their medical certification. The EU action does note a trend in a regulatory consensus that an AHI>15 may be the point where driving may not be safe. Here in the US the Federal Motor Carrier Safety Administration (FMCSA) in its bulletin to medical examiners[2] stressed that its goal is to identify drivers with an AHI>15 . This is only a regulatory consensus and there was no research cited in either regulatory action to support the AHI>15. In fact research on commercial drivers, sleep apnea, and crash risk in the US is “mixed at best”.[3] Reactions to the EU legislation from groups here in the US involved with the regulatory lobbying on sleep apnea in trucking[4] have been mixed. Scott Grenerth Regulatory Affairs Specialist with the Owner Operator Independent Drivers Association which has been opposed to mandatory OSA screening for CMV operators responded. “OOIDA supports testing and treatment for OSA when it is necessary and indicated by a driver’s family physician. OOIDA suspects that the same interests which are pushing for mandatory screening in the U.S. are behind the mandate in the E.U. No doubt those interests will profit from mandated testing while providing questionable safety benefits to the taxpayers of the E.U. who will be paying for the questionable testing.” Wanda Lindsay founder of The Lindsay Foundation who lost her husband to a truck driver with diagnosed but untreated sleep apnea responded ““In theory testing all drivers would be the ideal. However, I am afraid the sheer magnitude of monitoring and enforcing something on this scale might bog down the whole process and produce little positive results. I do believe, from articles I’ve read, that many other countries are far ahead of the U.S. in addressing the problems related to obstructive sleep apnea.” It will be interesting to watch how this new directive works out with EU member nations. [1] COMMISSION DIRECTIVE 2014/85/EU of 1 July 2014amending Directive 2006/126/EC of the European Parliament and of the Council on driving licences, http://eur-lex.europa.eu/legal-content/EN/TXT/HTML/?uri=CELEX:32014L0085&from=IT (Accessed 6/14/15) [2] FMCSA issues advisory on Sleep Apnea, Sleep Scholar 1/23/15 http://www.sleepscholar.com/fmcsa-issues-advisory-on-sleep-apnea/ (Accessed 6/14/15) [3] Commercial Drivers with Sleep Apnea: It’s Still Hit or Miss, Journal of Clinical Sleep Medicine, April 2015, http://dx.doi.org/10.5664/jcsm.4590 Barbara Phillips, MD, MSPH, FCCP; Bob Stanton, BS (Accessed 6/14/15) [4] Sleep Apnea Testing in Transportation: It’s not medical guidance anymore, It’s full blown politics now, Sleep Scholar, 1/5/2014 http://www.sleepscholar.com/sleep-apnea-testing-in-transportation-its-not-medical-guidance-anymore-its-full-blown-politics-now/(Accessed 6/14/15)