“The Hygienist’s Role in the Assessment of Sleep Apnea”

By : Sue Ellen Umali-Lee

As your cavitron buzzes away you suddenly notice that your patient is snoring in perfect rhythm with your ultrasonic scaler.  You check your notes and realize that this happened at their last hygiene appointment and even the one before this.  Is this normal or are your scaling skills so amazing they have a soothing effect?  Probably not!!!  Should this concern you?  Being the caring hygienist you are and one fully skilled in the assessment of the periodontium, you start to wonder why this is happening to this patient and not others.  Most of the time, patients are pale-knuckled in the chair until their treatment is complete to the point where you sometimes have to pry their fingers off the arm rest.  You look at your patient’s file to see if there is anything that you can correlate to her sleeping episodes.  She’s a petite young lady in her mid thirties.  Since you’ve built great rapport with her, you know that she isn’t married and doesn’t have any children so you start to wonder.  Yours and the dentist’s clinical findings indicate she’s a heavy bruxer or clencher and you’d been doing your due diligence in trying to get her to commit to wearing a night guard but she strongly believes she doesn’t need one because she sleeps with her mouth open!  Sound familiar?

What else can it be?  She’s got you stumped.  Most would leave it at that and just book her next hygiene appointment but you know sometime doesn’t feel right so what do you do?

Etiology and Assessment are among the most important tools any clinician has in their arsenal especially when it comes to the field of dental hygiene.  We have such an amazing ability to make a difference with our skill set because of the information we can share with patients.  Educating them about their periodontal condition, decay prevention, and about the connection between oral health and their systemic health are what we discuss on a daily basis so it’s no wonder when something seems off with our patients, we notice.

Obstructive Sleep Apnea has been a concern for quite some time but until now, our knowledge has been limited.  We never thought to extend our assessment to the tongue, tonsils and how wide a patient can open.  Sure, we were taught to measure these things in hygiene school but weren’t really taught how to apply them in practice or what their significance is.  As part of our complete oral examination, we assess the tongue using the Mallampati Score.  Traditionally, this score is used to assess intubation for general anesthesia but the classification a patient is diagnosed with can determine tongue obstruction and its contribution to obstructive sleep apnea.1  

The assessment of the tonsils is also significant as this may too contribute to airway obstruction.  The Friedman grading scale is what we use clinically in our practice to grade the tonsils from 0 to 4 – 0 being no tonsils are seen or a tonsillectomy has been done to 4 where the tonsils are actually touching or “kissing.”  To ensure that we don’t base our findings solely on what we see clinically, we also have a patient fill out a questionnaire which also helps us determine if they may have sleep apnea or are at risk.  Click here to see a sample of the sleep apnea questionnaire we utilize.  

So what do you do if you suspect your patient has sleep apnea?  As clinicians, it is important that we collaborate with other medical professionals and in this case, it is very necessary.  You would then recommend that your patient see his or her medical doctor and request a sleep test to be done.  It is only through the sleep test that confirmation of a Sleep Apnea Diagnosis can be made.  Inform your patient that if their medical doctor doesn’t feel that it is necessary, they can discuss the findings with you.  Unfortunately, this has occurred but we are more than willing to share our finding with their medical doctor.

When a final diagnosis has been made then the proper treatment for sleep apnea can be administered.  Until treatment is rendered, it is best that certain dental treatments be postponed as they may add to the patient’s risk.  For more information on Sleep Apnea, click here!