Why a Whole Health Approach to Obstructive Sleep Apnea Helps Patients with Excessive Sleepiness

A dental sleep medicine practitioner integrates CT scans, allergy testing, blood testing, and vital systems assessment testing under one roof.

As a dental sleep medicine practitioner, I am tasked with delivering an oral appliance that will effectively treat my patient’s obstructive sleep apnea (OSA). Yet even with a properly calibrated device and a compliance rate that exceeds that of CPAP,1 many patients still suffer from symptoms such as chronic fatigue that are related to or that coexist with their OSA diagnosis.

An anecdotal analysis of my patients suggests that a significant portion still suffer from fatigue and sleepiness, even after successful treatment of their condition with a mandibular advancement device (MAD), just as they do with PAP therapy.2 Unsurprisingly, the frustration that patients experience due to their continued suffering affects their willingness to continue to comply with treatment. It’s a cycle that, for me, has necessitated the redefining of my patient-care approach to identify, and in some cases, screen for additional underlying factors that are contributing to patients’ overall sleep health.

Getting to the Root of Sleep Issues

Most experienced dental sleep medicine practitioners routinely talk to their patients about strategies for and contributors of efficient sleep. Proper sleep hygiene and the importance of maintaining a healthy weight are two examples. And while those topics are undoubtedly important to stress with all patients, my team and I strive to push even beyond these fundamental conversations in the hope of providing patients relief from their symptoms and an improvement in oral appliance long-term compliance rates.

It’s important to note that a crucial first step prior to performing any diagnostic or treatment protocol is a thorough review of each patient’s entire health history. This will enable dental sleep medicine practitioners to anticipate potential unaddressed contributors to sleep health, while also considering and respecting the efforts that physicians or other practitioners have made or are making with regards to the patient’s health.

To facilitate a whole health approach, Sleep Dallas, the dental sleep medicine practice I founded, has a phlebotomist, nurse practitioner (overseen by an MD), and several medical assistants on staff. That way, we can get to the root of many sleep issues on site.

CT Scans to Get the Full Picture

Through diagnostic tools like a polysomnogram (PSG) or home sleep test, sleep professionals confirm the existence of a patient’s OSA as well as its severity, giving us the information we need to administer treatment. Yet as we know, there are a variety of anatomical factors that contribute to a patient’s OSA, which makes a CT [computed tomography] scan—two-dimensional imaging of the airway that’s commonly used in preparation for surgical treatment of the condition—a valuable resource for practitioners administering MAD therapy.

A pre-treatment CT scan—which, at Sleep Dallas, is performed by a medical assistant and sent out for interprepation—is a powerful evaluation tool that helps uncover potential factors in a patient’s OSA such as enlarged turbinates, deviated septums, and other pathology that could be obstructing the airway.

Allergy Testing to Improve Fatigue

Allergies are a common source of nasal obstruction and also a potential contributing factor in patients who experience obstructive apneas while sleeping.3 For a patient undergoing OSA treatment, allergies can diminish the efficacy of both CPAP and oral appliance therapy, producing an obstacle to relieving their symptoms.

Identifying the culprit allergen and a possible solution through allergy testing allows us to affect both treatment outcomes and overall sleep efficiency. Also, with allergies ranging from a mere annoyance to utterly debilitating during waking hours, we are often able to have a significant impact on the patient’s overall quality of life.

At Sleep Dallas, our phlebotomists perform the allergy testing and a nurse practitioner interprets the results.

Blood Testing to Uncover Nutrient Deficiencies

The link between nutrient deficiencies and sleep problems has been well-researched and documented. When a patient has an underlying deficiency—especially in iron,4 vitamin D,5 or vitamin B126—the likelihood of that patient continuing to experience fatigue, despite effective treatment of their OSA, is quite high.

Blood testing, performed and reviewed by a nurse practitioner, provides us the necessary information to anticipate potential contributors to persistent fatigue, while also giving us the opportunity to identify possible indications of coexisting health conditions like hypothyroidism7 or habits like closet smoking that may be impacting a patient’s sleep and overall health. We are then able to address nutrient deficiencies in conjunction with MAD therapy to more effectively impact a patient’s treatment outcome that is related to fatigue.

VSAT to Identify Risk Factors of Known Comorbidities

The list of obstructive sleep apnea comorbidities and their associated statistics are downright frightening: a significantly increased risk of diabetes;8 a 140% increase in the risk of heart failure, a 60% increase in the risk of stroke, and a 30% increase in the risk of coronary heart disease,9 to name a few.

From a whole health patient care perspective, effective treatment of OSA is just one piece of the pie, and dental sleep medicine practitioners can serve as a key line of defense against the condition’s common comorbidities. For those patients who come in without prior or recent screening, a vital systems assessment test (VSAT), which tests a patient’s sudomotor function,10 heart rate variability,11 and pulse wave velocity,12 can give practitioners a first indication that—beyond their OSA—it may be time to discuss seeing a specialist to address other issues.

Influencing Treatment of Mental Health Comorbidities

The link between sleep disorders like sleep apnea and insomnia and mental health comorbidities, such as anxiety and depression, is undeniable. Studies have shown that nearly 20% of patients with depressive syndrome may present with OSA and vice versa,13 and a significant number patients diagnosed with insomnia also suffer from anxiety and/or depression.14

Given this knowledge, we have an opportunity to influence a patient’s likelihood of seeking treatment for their mental health conditions in parallel with their treatment for sleep issues by simply having conversations with patients and maintaining a network of trusted cognitive behavior therapy resources to whom we can refer them.

Kent Smith, DDS, ABDSM, ASBA

Kent Smith, DDS, ABDSM, ASBA

Encouraging a Collaborative Environment Among Specialists

Despite our siloed healthcare environment, a whole-health patient-centered approach to treating OSA provides the ideal platform to foster an improved, collaborative network in sleep medicine and beyond. As we become effective and efficient at identifying the coexisting conditions that contribute to a patient’s sleep health, we’ll also see increased opportunity to further collaborate with and refer to specialists in sleep medicine and the broader medical community, all for the benefit of patients’ treatment outcomes and relief. It’s truly a win-win.

Kent Smith, DDS, ABDSM, ASBA, has been treating patients for over 30 years. He is a Diplomate of both the American Board of Dental Sleep Medicine (ABDSM) and the American Sleep and Breathing Academy (ASBA) and serves as president of the American Sleep and Breathing Academy. He is founder and clinical director of Sleep Dallas, a dental sleep medicine practice with two locations in the Dallas metro area.

References

1. Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, et al. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax. 2013 Jan; 68(1): 91–6.
2. Launois SH, Tamisier R, Lévy P, Pépin JL. On treatment but still sleepy: cause and management of residual sleepiness in obstructive sleep apnea. Curr Opin Pulm Med. 2013 Nov;19(6):601-8.
3. McNicholas WT, Tarlo S, Cole P, Zamel N, et al. Obstructive apneas during sleep in patients with seasonal allergic rhinitis. Am Rev Respir Dis. 1982 Oct;126(4):625-8.
4. Patterson AJ, Brown WJ, Powers JR, Roberts DC. Iron deficiency, general health and fatigue: results from the Australian Longitudinal Study on Women’s Health. Qual Life Res. 2000;9(5):491-7.
5. Roy S, Sherman A, Monari-Sparks MJ , Schweiker O, et al. Correction of Low Vitamin D Improves Fatigue: Effect of Correction of Low Vitamin D in Fatigue Study (EViDiF Study). North American Journal of Medical Sciences. 2014 Aug; 6(8):396-402.
6. Mayer G, Kröger M, Meier-Ewert K. Effects of vitamin B12 on performance and circadian rhythm in normal subjects. Neuropsychopharmacology. 1996 Nov;15(5):456-64.
7. VanDyck P, Chadband R, Chaudhary B, Stachura ME. Sleep apnea, sleep disorders, and hypothyroidism. Am J Med Sci. 1989 Aug;298(2):119-22.
8. Pinto J, Knoll Ribeiro D, Freitas da Silva Cavallini A, Duarte C, et al. Comorbidities Associated with Obstructive Sleep Apnea: a Retrospective Study. Int Arch Otorhinolaryngol. 2016 Apr; 20(2): 145–50.
9. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163:19–25.
10. Illigens B, Gibbons C. Sweat testing to evaluate autonomic function. Clin Auton Res. 2009 Apr; 19(2): 79–87.
11. Hillebrand S, Gast KB, de Mutsert R, Swenne CA, et al. Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: meta-analysis and dose-response meta-regression. Europace. 2013 May;15(5):742-9.
12. Ben-Shlomo Y, Spears M, Boustred C, May M, et al. Aortic pulse wave velocity improves cardiovascular event prediction: an individual participant meta-analysis of prospective observational data from 17,635 subjects. J Am Coll Cardiol. 2014 Feb 25;63(7):636-46.
13. Shoib S, Malik J, Masoodi S. Depression as a Manifestation of Obstructive Sleep Apnea. J Neurosci Rural Pract. 2017 Jul-Sep; 8(3): 346–51.
14. Johnson E, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: Exploration of the direction of risk. J Psy Research. 2006 Dec; 40(8): 700-8.

from Sleep Review http://www.sleepreviewmag.com/2018/08/whole-health-approach/

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