About three years ago Gary Klein, a 52-year-old dentist in Hamilton,

was diagnosed with obstructive sleep apnea (OSA), a temporary

cessation of breathing due to the collapse of the upper airway during

sleep. At 33 apnic events per hour, he fell into the moderate category

of OSA and was told he had only two options for treatment: a CPAP

(continuous positive airway pressure) device or surgery. Klein started

to look at other possibilities, he says, and "that’s how I got

involved in dental sleep medicine."

Sleep medicine is a relatively new field, and, among both physicians

and dentists, many practitioners may not be fully up to date on

research and treatment options. As a result, prejudices exist, one

being that OSA is only a problem for people who are fat. "Granted, the

more obese you are, the worse it is," says Klein, but no one picked up

his problem initially because he was not heavy. "They blew it with

me," he remembers. "They were shocked when I came back [from the sleep

lab] with 33 apnic events an hour."

Klein explains that during an apnic event "the airway collapses; it’s

like a Chinese finger puzzle – you pull either end and it gets narrow

in the middle." Say you have an airway opening with a circumference of

X. When you breathe in through the diagram, air comes into the throat

through negative pressure; normally, when the air is sucked in, the

airway narrows but doesn’t close. In OSA, for some reason (the most

common being overweight, in which fat deposits accumulate on the

outside of throat and push it closed) the circumference reduces, maybe

to one-half X; now the airways touch and form a plug. "The harder you

pull, the narrower it gets," says Klein. "The patient is not getting

air and tries to breathe harder, creating more of a plug, and there is

an apnic event." (Sometimes, the airway may just get narrow, causing

shallow breathing, or hypopnea.)

The primary symptoms of OSA are loud snoring, silent periods followed

by a loud gasp, and awakening in the morning unrested; untreated it

can be dangerous to a person’s health. Normally the body simply

breathes in response to the build-up of carbon dioxide. But with an

apnic event, says Klein, "the body and brain panic," saying, "I need

oxygen." The brain senses danger and sends epinephrine from the

adrenal glands, getting the heart to beat faster and the throat to

open, affecting organs all night long. Former Green Bay and

Philadelphia Eagles football player Reggie White died in December, at

age 43, of complications of OSA and lung disease.

Although Klein himself treats OSA with dental devices, he states

unequivocally that "CPAP is the gold standard for treatment of OSA."

The CPAP acts as an "air splint," keeping the airway open by blowing

air into the throat and pushing the tissues apart, just as a balloon

expands when air is blown into it. The CPAP’s pressure is raised until

the apnic events start to disappear.

But the problem with CPAP, continues Klein, is that "70 percent of

patients stop it after one year," for a variety of reasons: they can’t

stand the feeling of claustrophobia they get from the mask; they feel

young and virile and can’t tolerate "wearing such a thing;" or they

can’t stand air blown down the nose all night, the drying out of the

nasal passages, or simply the nonstop noise. "Those who continue

usually get such a benefit that they have the incentive to continue

using it."

Klein treats snoring as well as OSA with dental devices. According to

the Academy of Sleep Medicine, he says, especially for mild OSA, only

the CPAP is more effective than all of these appliances; surgery comes

in third. He himself has worn five or six different appliances, all of

which are FDA approved. "Oral appliances activate muscles in the floor

of the mouth that attach to the base of the tongue and pull the tongue

slightly forward," he explains. These appliances try to spread the

tissues apart a little more so they don’t close down completely, but

"depending on the severity of the apnea, it doesn’t always work." As

the number of apnic events go up past 20 per hour, the odds of success

with appliances starts to go down.

Today 15 to 20 percent of Klein’s practice has to do with sleep. He

had always been a general dentist, focusing on cosmetics and

reconstruction, but after his diagnosis with OSA, he trained himself

to work with sleep appliances "by being my own patient, seeking out

courses, and networking with other dentists who do it." Although last

year the Academy of Dental Sleep Medicine had about 640 members

internationally, "the problem," he says, "is that dentists say they do

this, but are not really trained." One issue is that many dentists use

a one-size-fits-all appliance made by the lab, which may not be as

effective as a custom-made one.

"Almost everyone is a CPAP failure when they come to me," he says.

First he examines potential patients to see if he has a chance of

helping at all. If there is too much tissue or the index too high, he

does turn people away. For patients who have not been to a sleep lab,

he uses the Epworth Sleepiness Scale to assess whether they are

primary snorers or suffer from a sleep disorder. Patients indicate how

likely they are to fall asleep in a variety of situations, assigning a

score of 0 to 3. If their total score is above 9, Klein will suggest a

visit to their physicians for referral to a sleep study.

Many of his patients initially come to him with complaints about

snoring. "Many couples sleep in separate bedrooms because of this

problem," he observes. Snoring gets worse as people age, he says,

because of decreased airway volume, often caused by increased weight.

Many women don’t become snorers until menopause, which causes changes

in the muscle tone of the neck.

Although snoring is a symptom of OSA, the two are not synonymous, and

snoring itself can keep a person awake, according to Klein. There are

five levels of sleep; the first two are lighter, and the second two

are slow wave or dopa sleep, which are the refreshing levels. The

fifth is REM sleep, a lighter sleep during which dreams occur. "If

you’re a snorer, you may not stay in level three long enough, and get

thrown back into level two," says Klein. This sleep interruption

creates UARS (upper airway resistance syndrome), which is chronic

daytime sleepiness, not caused by OSA but often associated with

snoring and brief, frequent arousals.

Dental appliances can eliminate snoring, and Klein says that if he can

correct the snoring, apnea may be corrected simultaneously. He makes

his own appliances, which are molded to go over the top and bottom

teeth. To help position a device, he uses a tharyngometer, which sends

acoustic sound waves down the throat. When the devices are

appropriately positioned and working effectively, the patient reports

not snoring and feeling good in the morning. Klein uses a follow-up

sleep study to check the efficacy of the device and to ensure that OSA

has been corrected.

Sleep is a relatively new field, accompanied by research that supports

new approaches and changed beliefs. For example, if you are nodding

off when you get up in the morning, that may signify a problem, but if

it’s happening at three in the afternoon, it’s probably just part of

the circadian rhythm – the daily fluctuation of behavioral and

physiological functions, including sleep and waking. "For years,"

observes Klein, "power naps were debunked; now they are viewed as

20-30 minute recharges of the batteries." There has also been some

rethinking about whether tonsils should come out if a child is a

snorer and about whether children diagnosed with ADD simply may not be

sleeping properly.

Perhaps indicative of the coalescing of the sleep field is the fact

that the Academy of Dental Sleep Medicine and the Academy of Sleep

Medicine are under the same roof in Chicago. "They are cooperating

tremendously," says Klein. "At our national conference more than half

of the presenters are MDs. As we see efficacy increase, cooperation

will also increase."

Gary S. Klein DMD PA, 3705 Quakerbridge Road, Suite 203, University

Office Plaza II, Hamilton 08619. 609-586-6688; fax, 609-586-8744.

Facebook Comments