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
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
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.