- These patients have a medical problem, not a dental problem
- I will have to choose between treating the sleep problems first and their dental needs
- How to listen to the patient…and actually hear what they said!
Treating patients for sleep apnea, snoring, and sleep related issues is one of my favorite procedures in my practice. It’s incredibly rewarding. We get to change the quality of life for every patient. And the patients want us to help them. Our sleep patients actually look forward to coming to their appointments. But it didn’t start out that way.
Most dental procedures are pretty much isolated from the rest of the body. A tooth has a cavity. All you have to do is get the tooth numb, remove the decay, restore the tooth, and adjust the bite. Problem solved. Very little if any of the rest of the body has been affected, either by the cavity or the filling. But with sleep apnea the entire body is affected in some way, both mentally and physically. If a patient does not get enough REM sleep they will be a frustrated patient. And if their body is starved for oxygen every night many of their internal systems will have issues. As dentist we have a tendency to see the teeth and forget about the rest of the body. With sleep apnea every part of the body both inside and out has to be factored in. If you’re considering getting involved in treating sleep apnea don’t let this scare you. I get it. You have been out of dental school for a while and most of the anatomy lessons have been replaced with bonding protocols and tooth prep guidelines. And I promise you it’s not hard to learn again how the body works. Yes some lectures make it complicated. It’s not. And the PSG or sleep study tells you most of what you need to know. And you will have to dedicate some time to learning how all the info from the sleep study ties together. There is a lot more to it than just the AHI number. Another issue you will have to deal with is all the medications patients are taking. It will amaze you! For dental patients our main concern is usually over dry mouth or clotting time when it comes to medications for medical problems. For sleep apnea patients many of the medications patients are taking help one area of the body but can also affect their sleep. You can have a dental patient stop taking their blood thinning medication so you can remove a wisdom tooth. You can’t have a patient stop taking their cholesterol medicine even if it keeps them up all night so you can help them sleep. And then there is the anxiety patient taking antidepressants to help them fall asleep. Yes it does them to sleep. But it also suppresses the REM stage so the patient spends a lot of time in stage 1 which is light sleep. So they wake up from any stimulus all night long. What I didn’t understand when I started treating sleep apnea is that there would be so many variables I would be confronted with for each patient. So I had a lot of failures or what I perceived as failures. In the dental world either you removed all the decay or you didn’t. Fail. Success. In the medical world sometimes close is the best you can achieve. There are just too many variables you simply cannot control. I was not ready for that. So when I helped a patient get his AHI from a 65 to a 12 I felt I failed. An AHI of below 5 is considered healthy. But for an AHI 65 patient 100 lbs over weight, BMI 35, heart problems, diabetes, and CPAP intolerant an AHI of 12 is very much a success. Now that he is sleeping better, heart is not racing all night, he has more energy, etc I have given him his life back. And with more energy he will probably lose a few pounds and that will lower his AHI closer to below 5. I wish I had known from the beginning to accept that medical care is not as precise as dental care. Just too many variables both known and unknown that can’t be controlled. These are medical patients, not dental patients. I am a dentist treating a medical problem with a dental device. Wish someone had told me this in the beginning.
That last sentence leads me to the next thing I wish I had known when I started treating sleep apnea. Not every tooth needs to be fixed right now. Getting air into the body is more important than fixing a broken molar cusp that fractured off a decade ago. Patients were coming to me to treat their sleep apnea, a medical problem. And I went into a dental mindset and spent the first 30 minutes talking about their dental problems. In my mind it made sense to restore all their dental problems so the appliance would not have be altered if they had any dental work done. In the patients mind it didn’t matter if their teeth were broken if they were not able to breath. Being able to breath and sleep at night was their priority. It wasn’t mine. Because I am a dentist I couldn’t help myself. I made their teeth the priority. And as you can imagine I lost a lot of sleep apnea patients because of this. Am I saying we make appliance to fit over periodontally involved teeth? Of course not. Every day in my dental practice I have to prioritize treatment based on my patient’s finances, work schedule, etc. This is the same situation. I just didn’t see it that way in the beginning. Now we show the new sleep apnea patient their digital radiographs and digital photographs that are part of my initial exam. When they look at the pictures they can see their teeth have problems. I say up front that I respect they did not come to me as a dentist to treat their teeth. And when they have some of their dental work done their appliance will need to be adjusted to fit over the new dental work. And that it’s OK to treat their sleep apnea first. If I see some teeth with advanced bone loss or for some reason taking the appliance on and off may cause a problem I let them know. Sometimes the patient then chooses to let me or their own dentists restore their dental problems first. And sometimes I simply block out the undercuts on those teeth and move forward making the appliance. It’s ok to treat the sleep apnea first. Actually in my opinion it’s a bigger issue than the teeth. Wish someone had told me this in the beginning.
And this leads me to the third thing I wish I had known. How to really listen to patients. Yeah that means closing my mouth and not trying to explain everything. My sleep apnea patients tell me every day that they wish their medical doctor would listen to them the way I do. They hate all their medications. They hate how they feel. They are confused as to what’s being done. They still don’t understand why that had to get a sleep study. They have so many questions and everyone keeps talking at them instead of to them. One of the best things I have learned to do is start the conversation with a sleep patients by stating that today is only about answering any questions you have. They are usually hesitant at first. But once they realize you really intend to answer all their questions they truly begin to open up. I also read and explain to them any sleep study they have. It doesn’t matter how old it is. Yes they will need a current study before I can start treatment. But many of my new patients are still angry and confused because no one told them why they had to get a study, what the study would be like, and then no one explained the results. The sleep physician just told them the AHI number and fitted them for a CPAP. That would have upset me too. Before you ask a patient to get a new sleep study it is a good idea to ask them how the first one went. Wish someone had told me this in thebeginning.