Friday, September 30, 2016

Sleep Interrupted

By Jacqueline Mitchell

For 50 million chronically exhausted Americans, a pioneering program at the dental school is leading the way to a good night’s rest

illustration for sleep story

“It’s very important we get some sort of treatment that lets these people function,” says Jeffrey R. Prinsell, D79. Illustration: Scott Bakal

By the time Mary Keeler arrived at the Tufts Dental Clinic, she hadn’t had a good night’s sleep in more than 15 years. Since 1993, Keeler had experienced daytime exhaustion so severe it interfered with her health, her mood, her work and her relationships. “I was sleeping my life away, but I couldn’t seem to get to the bottom of it,” says Keeler, now 61. After years of counseling, testing and trial and error, she eventually found the solution to her sleeplessness in what may seem an unlikely place—the dentist’s office.

Maybe it’s a product of our 24/7 lifestyles, but for many Americans, quality sleep is getting harder to come by. In 2008, the National Sleep Foundation surveyed 1,000 people for its Sleep in America Poll and found that 65 percent of them reported having a hard time falling or staying asleep more than once a week.

Though sleep medicine is a growing field, fewer than 8,250 of the nation’s 750,000 physicians belong to the American Academy of Sleep Medicine. That’s not even close to enough health-care providers to handle the estimated 50 million to 70 million Americans who are living with one or more of the 85 medically recognized chronic sleep disorders—including obstructive sleep apnea—that result in overwhelming daytime drowsiness. Untreated sleep disorders can lead to potentially deadly health problems, not to mention the hazards the chronically sleepy pose on the road and in the workplace.

Now, Tufts’ new Dental Sleep Medicine Program, the first university-level curriculum of its kind in the United States, is training dentists—with their expertise in oral anatomy, surgery and therapeutic appliances—to screen and treat their patients who suffer from sleep disorders, primarily obstructive sleep apnea, a condition in which a patient literally stops breathing for 10 seconds or more.

First offered in the fall of 2009, the semester-long course provides postgraduate dental students classroom instruction and clinical training in sleep medicine. Students participate in patient evaluations, observe sleep studies and assist with fitting and adjusting oral appliances designed to give their patients a good night’s sleep.

“I applaud the educators at Tufts School of Dental Medicine for the implementation of their Dental Sleep Medicine Program and hope that many dental schools will follow their lead,” says Jeffrey Pancer, president of the American Academy of Dental Sleep Medicine.

The sleep medicine program is offered as an elective to all 144 of Tufts Dental School’s postgraduate students, and those in certain postgrad programs are required to take the course to earn certification in their specialties. “We didn’t want it to be a separate program, because we want sleep medicine to be involved in all aspects of dentistry,” says Noshir Mehta, DG73, DI77, professor and chair of general dentistry and director of Tufts’ Craniofacial Pain, Headache and Sleep Center, which developed the program. “Ultimately, we’d like every postgraduate student to take the course,” says Mehta.

Tufts has incorporated sleep medicine into its D.M.D. program for several years now to provide students with the tools “to identify patients who should get tested at a sleep center,” says Leopoldo P. Correa, the course director and head of the school’s dental sleep medicine section. Extending the curriculum to postgraduates preparing for specialty practice means “more students will gain the skills and in-depth experience they need to integrate dental sleep medicine into their practices,” he says.

Gasping for Air

The most common sleep disorder is obstructive sleep apnea (OSA). Though figures vary, the National Sleep Foundation estimates that OSA afflicts more than 18 million adults in the United States—that’s nearly one in 17 of us—which makes the disorder as common as asthma and diabetes. In 1993, the Wisconsin Sleep Cohort Study found that among middle-aged people, as many as 10 percent of women and a quarter of men suffer from OSA. What’s more, the Wisconsin study suggested that as many as 5 percent of adults may have undiagnosed OSA.

Like many sleep disorder patients, Mary Keeler’s path to diagnosis and treatment was a winding, often frustrating one. For a long time her sleepiness was mistaken for a symptom of depression or a side effect of the medication she took to treat the depression. Finally, in 2006, a counselor suggested Keeler undergo a sleep study. After spending a night in a hospital hooked up to machines and monitored by sleep experts, Keeler was diagnosed with moderate obstructive sleep apnea.

OSA occurs when the tongue and/or soft tissues lining the throat collapse into the airway, causing pauses in breathing and loud snoring throughout the night. The pauses—each called an apnea, for the Greek word meaning “no breath”—can last anywhere from a few seconds to more than a minute. Apneas can occur hundreds of times in a single night. Each apnea disrupts sleep, as the person struggles to breathe, even if the sleeper never fully wakes up.

That’s why OSA patients can sleep for hours but still feel exhausted. The lack of restful sleep can lead to cognitive impairment, irritability, forgetfulness and depression. Beyond that, the drop in blood oxygen levels during episodes of apnea stresses the heart, putting OSA sufferers at greater risk for hypertension, heart attack and stroke.

Deadly Deprivation

Because being male, middle-aged and overweight are all risk factors for cardiovascular diseases as well as OSA, quantifying the risk and disentangling the causes and effects is something of a chicken-and-egg problem. But even back in 1993, the Wisconsin Sleep Cohort Study found a correlation between the severity of sleep apnea and severity of hypertension. More recently, in 2009, sleep researchers at Johns Hopkins concluded that sleep-disordered breathing is associated with an increased risk of mortality from “all causes,” especially for men ages 40 to 70. That data was culled from the national Sleep Heart Health Study, which followed 6,000 participants over 15 years in the largest community cohort study of sleep.

But while sleep researchers continue to mine the data, it’s clear that untreated apnea is poised to become a significant public health issue.

The gold standard for treating obstructive sleep apnea is a contraption known as a continuous positive airflow pressure machine, or CPAP, which forces air down a patient’s throat to create what Mehta describes as an “air splint” that keeps the airways open.

When Keeler’s sleep physician outfitted her with a CPAP—which features an air pump, up to six feet of tubing and an airtight face mask—she had a very common reaction to the apparatus. “Well, I hated it. I absolutely hated it,” says Keeler, who found the mask extremely awkward and uncomfortable. And she wasn’t the only one who hated the CPAP. Her husband couldn’t sleep in the same room as the breathing machine, which produced what Keeler describes as “white noise [that] at first seemed pretty minor. But as the night wore on, the sound seemed to increase in intensity.”

Luckily, Keeler’s sleep physician was Greg L. Schumaker, an assistant professor of medicine at Tufts. He referred her to the dental school, where she met Correa. After conducting a clinical exam and choosing from among the 70 corrective appliances on the market, Correa customized one for Keeler.

A follow-up sleep study found that while the apnea was gone, Keeler wasn’t getting enough REM (rapid eye movement) sleep, the deep slumber that promotes cognitive functioning. It was a problem her sleep physicians were able to treat with medication. “That shows how important it is for sleep physicians and dentists to collaborate,” says Correa.

“All of a sudden, I woke up like a new person,” Keeler says. “I thought, ‘So that’s what it feels like to get a good night’s sleep.’ ”

Weighed Down

Though sleep apnea didn’t appear in the medical literature until 1965, the disorder has probably been around a long time. OSA was once known as “Pickwickian syndrome,” after the character Joe in Charles Dickens’ first novel, The Pickwick Papers. Joe’s obesity and tendency to fall asleep at odd times during the day are consistent with symptoms of OSA.

Carrying extra fat—and even muscle, in the case of some athletes—around the neck can put pressure on the throat tissues, especially for shorter-necked people, and cause obstructive sleep apnea. Aging, too, causes the tissues to lose tone, making them more likely to sag and block the airway while in repose. “We used to think nothing of snoring. Now we know it’s a risk factor for apnea,” says Mehta.

On top of that, sedatives such as alcohol or prescription drugs can cause further slackening of the upper airway tissues. Three years ago, Tim, who asked that his last name not be used, was drinking too much and gaining weight. His wife’s complaints about his snoring, more than his chronic sleepiness, eventually sent him to a sleep clinic in New Hampshire, where the 54-year-old was diagnosed with moderate sleep apnea. Like Keeler, Tim couldn’t get used to the CPAP device. “I tried it, but I couldn’t tolerate it,” he says. “The mask fell off constantly, no matter how many times I had it adjusted.”

Eventually, his doctors referred him to Tufts Dental School and Correa, who fitted Tim with a two-piece mouth guard that holds his lower jaw slightly forward while he sleeps. Right away, Tim says, his nighttime breathing began to improve.

As anyone trained in CPR knows, pulling the lower jaw forward automatically opens the upper airway. However, this repositioning of the jaw can also irritate the temporomandibular joint, or TMJ. Over the course of a year, Tim visited Correa every two or three months for tiny adjustments to the mouth guard. “There was some initial drooling,” Tim reports. “But the body adjusts over time. I’m very used to it now.”

Maybe it was his improved quality of sleep. Maybe it was visiting doctors’ offices so frequently—Tim can’t say—but sometime during his treatment, he quit drinking and lost 40 pounds. Today, Tim reports he feels great, sleeps soundly and is never drowsy during the day. His nights of exile to the living room sofa are over. “I’m back upstairs with my wife,” he says.

Risk Factors

Lifestyle changes like Tim made should be the first line of attack in treating sleep apnea. But they won’t work for everyone with a snoring problem or daytime sleepiness. “Years ago, only obese persons were considered likely to have OSA,” says Correa. “Recently we’ve been seeing that’s not always the case. It can be based on anatomical features.”

Certain physical characteristics—such as having small lower and upper jaws or a large tongue positioned relatively far back in the mouth—can increase the risk for developing sleep apnea. These are some of the things Correa, who sees about 100 apnea patients each month, looks for in all his new patients, even those who don’t come in complaining about OSA-related symptoms.

Jeffrey R. Prinsell, D79, a dentist and a physician, says about a quarter of his oral surgery practice in Marietta, Ga., is dedicated to helping apnea patients get a good night’s sleep. Prinsell is a founding member and former president of the American Academy of Dental Sleep Medicine (AADSM) and founding president of the American Board of Dental Sleep Medicine, which was established in 2004 to certify dentists who treat sleep-related breathing disorders.

“Tufts is a pioneer,” Prinsell says of the Dental Sleep Medicine Program. Prinsell and Correa were members of the AADSM curriculum committee that developed sleep medicine courses that any dental school could implement. Correa used those courses as a framework for the Tufts sleep dentistry curriculum.

As with Correa’s obstructive sleep apnea patients at Tufts, the vast majority of Prinsell’s patients respond well to some combination of the CPAP device plus oral appliance therapy. But about 10 percent have apnea so intractable that surgery is the only solution. For these patients, Prinsell can remodel nasal passages, adjust the jaw and even reposition the tongue. Other patients may need their tonsils removed. Tufts Dental School’s oral and maxillofacial surgery department also offers surgical treatment for apnea patients.

While these remedies may sound extreme, Prinsell points to the disastrous effects sleep disorders can have on the quality of life. “These patients are extremely tired; their performance at work suffers; they lose their libido; their bed partners leave them. And if [the sleep apnea] is left untreated, these people could die at night in their sleep,” he says.

Restless Nights, Daytime Hazards

Prinsell also wonders how many industrial mishaps might be caused by undiagnosed sleep apnea. A 2006 Institute of Medicine report, “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem,” found that daytime hypersomnolence costs $150 billion each year in accidents and lost productivity and another $48 billion in medical costs related to auto accidents involving sleepy drivers. The IOM report also found that 20 percent of all serious car accidents are caused by sleep-deprived drivers. “It’s very important we get some sort of treatment that lets these people function,” Prinsell says.

Dentists Against Drowsy Driving, a public health campaign launched by the American Academy of Dental Sleep Medicine in November 2008, is designed to raise awareness among health-care practitioners and the public about this life-threatening condition.

But, says Prinsell, the dental sleep medicine academy has just 1,800 members, an extremely small proportion of the 160,000 dentists who are members of the American Dental Association. “There are just a handful of us doing it,” he says, “so Tufts’ program is increasing the number of trained professionals who will help with the manpower shortage.”

“We pride ourselves that Tufts led the way in many different specialties,” says Mehta, the Tufts faculty member. “Dental sleep medicine is another place for us to be on the leading edge, both clinically and educationally.”

This story first appeared in the Spring 2010 issue of Tufts Dental Medicine magazine.

Jacqueline Mitchell can be reached at jacqueline.mitchell@tufts.edu.

Posted April 21, 2010