Screening for sleep disorders in the dental office: Better sleep for better health

by Kent Smith, DDS

It's 5:30 a.m. and your alarm goes off ... for the third (or is it the fourth?) time this morning. Sleep amnesia meets sleep inertia and, momentarily, the horn is honking as your mom picks you up from school. No, that's just the bleeping alarm telling you that once again, you have not had a sufficient amount of sleep. OK, so maybe this does not represent a typical day's start for you, but it is quite typical for about half of your team and patients.

Can't get to sleep by 10 p.m.? Caffeine may be the reason. To compensate, many people choose to have a nightcap, thinking it will allow them to initiate that blessed sleep cycle, but reality (and research) says you're only fooling yourself. Alcohol takes hours to metabolize, and even though you initially get some deep sleep, the continual work of the sympathetic nervous system in metabolizing the alcohol does not allow you to get the needed REM sleep you need to process memories and give you a sense of well-being the next day.

The effects of the alcohol wear off, and you remain in a lighter stage for the majority of the night. To make matters worse, that deep sleep you manage to get is robbed of its healing nature, as the mucosal tissues have swollen, pharyngeal muscles have weakened, and an obstructed airway has prevented some needed oxygen from entering your lungs. This airway resistance manifests as snoring and obstructive sleep apnea.

This poor and inefficient sleep has many negative consequences, including weight gain, slower reaction time (in driving, for example), fatigue, memory problems, and the inability to handle stress. You may actually think you're alert, and you may fool others, but recent research shows that once your attention is diverted from a task, it is very difficult to reengage. Sound like anyone you know?

If we are truly "dental physicians," we should have an interest in helping our patients maintain a more healthful existence. If we can practice good habits ourselves and can educate and treat our sleepy patients, it's truly a win-win.

Let's start with you and your team, so everyone can realize the importance of healthy sleep.

Set a goal for every team member to wake up each day without the aid of an alarm clock. As I mentioned, about half of your team will need some help in this area. To determine the amount of sleep you need, move your bedtime up 15 minutes every night until you wake up before the alarm goes off. This will determine how much sleep you need on an average night. You now have a goal for bedtime every night.

I urge you to make yourself an example first, so your team will be able to see your energy at 2 p.m. You can tell them how you now have the energy to go home and play with the kids and interact with your spouse. You can talk about your renewal with emotion and conviction. After you accomplish this, create a team contest that revolves around team members getting at least seven to eight hours of sleep every night. When this happens, they will be motivated to educate and encourage patients to revere their sleep, something we spend one-third of our lives doing.

But wait. If you go to sleep at 10 p.m. and wake up at 6 a.m., did you really get eight hours of sleep? Not likely. If you get seven or eight hours and are still fatigued, inefficient sleep is the culprit, and this is even more important than the total hours you get. To date -- and I have been testing patients, doctors, and their team members for many years -- the record for sleep efficiency I have seen is 98%. Proper sleep efficiency is considered to be somewhere in the range of 88% or higher, but I see a large percentage with less efficient sleep than this.

So, how can we improve efficiency? First, let's look at the primary thieves of healthy sleep, and the solutions will become somewhat self-evident.

• Snoring and sleep apnea are the primary culprits.
• Insomnia is equally important, but of interest is a recent study that showed most awakenings in insomniacs are related to obstructed breathing.
• Periodic limb movement -- this is heavily linked to airway obstruction -- clear the airway first and limb movements will typically abate.

Noticing a trend here? Is breathing important? More efficiency thieves …

During sleep:

• Pets in bed -- I have little luck breaking that habit with patients.
• Ambient light -- even the digits on the bedside clock can interrupt sleep.
• Ambient noises -- consider white noise to drown these out.
• A snoring bed partner -- going to another room does NOT cure the snoring.
• An environment too warm for consolidated sleeping -- 68 degrees is the warmest.
• Stress/anxiety/depression/sadness -- incidentally, antidepressants can negatively affect sleep.
• Cell phones -- is there any other type?
• Small children -- interruptions.
• Big children -- lack of interruptions ... or contact ... or curfew timeliness.
• Allergies -- work on a clean bedroom environment.
• Uncomfortable mattress or pillow -- find one that is right for you.
• Irregular bedtimes -- keep a regular schedule, even on weekends.

Prior to bedtime:

• Drinking liquids too close to bedtime -- if they cause you to awaken and relieve yourself.
• Lack of exercise -- new research says that even late night exercise for better sleep is better than none.
• Lack of sunlight -- your suprachiasmatic nucleus needs some clear signals for melatonin production.
• Medications -- many will have a negative impact on sleep.
• Nicotine -- withdrawal will awaken you.
• Technology -- even a backlit iPad will fool your brain into thinking it's 2 p.m. rather than 2 a.m.
• Napping -- if due to insomnia.
• Caffeine and alcohol -- just a reminder.
• Big or spicy meals close to bedtime -- Tums isn't the answer.

Wow. With all of these potential interruptions, bad habits, or lazy behavior, it's a wonder any of us ever achieve a good night of sleep. So, what are some treatment options for the inefficient sleeper?

Unfortunately, sleep aids are the first answer for many, but they are very often just the proverbial Band-Aid and certainly do not address the cause. Additionally, these typically depress the respiratory drive, creating more airway problems, and remove REM sleep, which is vital for humans. Do you wonder why the FDA has approved only two of these prescription sleep drugs for long-term use?

Most of the items I've mentioned can be solved with proper sleep hygiene, but not all. This is where you as the dentist can make a dramatic difference in the lives of your patients and your team. Sleep disordered breathing (SDB) is affecting the majority of your patients. You're as likely to find a patient with straight teeth as you are to find one who doesn't snore.

Snoring is bothersome, but its kissing cousin, sleep apnea, goes undiagnosed in the vast majority of patients, and our MD brethren have no time, much less the proper education, to screen for SDB. As a dental physician, you and your hygiene team spend considerably more time in the presence of your patients, and in my opinion, you are the health-care practitioners who hold the key to more healthy sleep for the masses.

Much has been written on this subject, so there is no need to elevate the importance if you are already aware of the implications. However, if you have yet to get yourself and your team educated, please find an institute, corporate entity, organization, or individual who can help you start screening for SDB. It's not a fad, and the problem is not going away. Be the one who makes a difference, saves a life, or repairs a marriage.

Has your alarm gone off?

Kent Smith, DDS, is a diplomate of the American Board of Dental Sleep Medicine. As "The Sleep Doctor," he hosts a radio show on sleep disorders every Tuesday at 1 p.m. on KAAM in the Dallas area. He can be reached at [email protected].