Taking a Nocturnal Look at the Neglected Health History
B Kent Smith DDS
published by theInternational Association of Comprehensive Aesthetics
As we look at the new patient paperwork, we see "interested in a smile makeover", and suddenly, we are blinded to any complications in their health history. If we bother to glance at that part of the form, it's only our moral nature assuaging ourselves of any guilt by reading, but not seeing, the written clues to our patient's overall health status.
Maybe you do actually contemplate each item checked. "Depression? Ah, that must be related to her ugly teeth – that's an easy fix!"…"Hypertension? Good, he's medicated."…"GERD? I'll have to make sure she's taking Prilosec so she won't eat away my porcelain!"
What you may not realize is that many of the disorders you see checked off are closely tied to their inability to breathe effectively while asleep. Regrettably, MDs get about five hours of education on sleep disorders, and they know very little about signs and symptoms related to these. With a health history at our fingertips and an oral cavity at the end of our loupes, we are much better suited to handle this chore. I would go so far as to say that it is our moral obligation to do so.
Taking a look at the cardiovascular system, we know that obstructive sleep apnea (OSA) is associated with systemic hypertension, atrial fibrillation, myocardial ischemia, atherosclerosis and an increase in cholesterol. Think hypertension is a good predictor for a myocardial infarction. You're right, but OSA is three times as likely to bring on an MI. Breathing without an antagonist while asleep is a key to a healthy heart, so if there are cardiovascular hiccups in the history, it's time to look for more indicators.
Another well-researched area related to OSA is the cerebrovascular system. Moderate to severe OSA patients are three to four times more likely to have a stroke within the next four years. In fact, OSA has twice the risk of factors such as hypertension and diabetes, so if your patient has a history of stroke, that's another red flag for you.
Many of your patients (about 10% of your adults) have diabetes. A 2007 Yale study reinforced a 1999 UCLA study showing that OSA patients are 2.5 times as likely to develop diabetes, independent of all other factors. Knowing that your diabetic patients could have their poor sleep to blame should give you a reason to ask more questions.
I don't know how many of you have questions about erectile dysfunction (ED) or loss of libido on your health history, but it's worth knowing about a 2006 study published in Urology. It reported that 80% of patients reporting to a sleep clinic with OSA symptoms had ED. Research has also shown that OSA reduces the level of testosterone, so loss of libido is a common symptom with these patients. I am actually surprised at the number of patients who willingly check that box on our history form.
Depression should be on everyone's health history. In sleep-disordered breathing, sleep is fragmented, and this altered architecture keeps the sleeping patient from getting the slow wave sleep they need for rejuvenation. Additionally, the hypoxemia which results from oxygen desaturation can result in cerebral metabolic impairment, leading to depressive symptoms. Even if your patient does not check this on their health history, you can often read it in their faces and see it in their countenance.
With the annual global antidepressant market topping $20 billion in 2007, the drug manufacturers are simply filling a need, and there's more need now than ever before. I received this email from a patient who contacted me about getting help for his OSA. "…I am at the end of my active life: marathons, two kids, and a happy life are gone."
Other items on the history that are linked to sleep-disordered breathing include bruxism (80% of bruxers have a degree of OSA), acid reflux (GERD), headaches, insomnia, nasal congestion, the use of a maxillary splint and prior orthodontic treatment. The scope of this article does not allow me to fully explore any of these, but please know that your patients have little knowledge of how their poor sleep is affecting their health, and you may be the doctor who turns on the light for them.
Kent Smith is the course director/instructor for Sleep Breathing Disorders at LVI Global, is the co-founder and co-director of the Dental Organization for Sleep Apnea, and is on the Medical Advisory Board of Sleep Healers®. He can be reached (and solicits your questions) at KentSmith@21stCenturyDental.com