Breathless: Oral Signs of a Silent Epidemic

EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

Breathless: Oral signs of a silent epidemic

A peer-reviewed article written by Kathryn Gilliam, BA, RDH, FAAOSH

PUBLICATION DATE: MARCH 2021

EXPIRATION DATE: FEBRUARY 2024

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS

This continuing education (CE) activity was developed by Endeavor Business Media with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity. No manufacturer or third party had any input in the development of the course content. Requirements for successful completion: To obtain three (3) CE credits for this educational activity, you must pay the required fee, review the material, complete the course evaluation, and obtain an exam score of 70% or higher. CE planner disclosure: Laura Winfield, Endeavor Business Media dental group CE coordinator, neither has a leadership nor commercial interest with the products or services discussed in this Breathless: Oral signs educational activity. Ms. Winfield can be reached at lwinfield@ endeavorb2b.com. Educational disclaimer: Completing a single continuing of a silent epidemic education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical Abstract experience that allows the participant to develop skills and This is an exciting time to be in dentistry. Dentistry and dental hygiene are expertise. Image authenticity statement: The images in this educational growing as medical specialties. As our understanding of the multiple links activity have not been altered. between the mouth and the body has increased, our roles have expanded to Scientific integrity statement: Information shared in this CE course is developed from clinical research and represents the most include comprehensive care of the patient’s whole health. One aspect of whole current information available from evidence-based dentistry. health care that can have an enormous life-changing and life-saving effect Known benefits and limitations of the data: The information presented in this educational activity is derived from the data and is to screen for sleep-disordered breathing. Breathing is the most essential information contained in the reference section. function of our bodies. Without oxygen, we cannot survive. Yet, until recently, Registration: The cost of this CE course is $59 for three (3) CE credits. breathing was not considered a part of dentistry’s scope of practice. With the Cancellation and refund policy: Any participant who is not advent of comprehensive health care and integrative dental medicine, focus 100% satisfied with this course can request a full refund by contacting Endeavor Business Media in writing. on the central role of airway and breathing disorders represents a shift in Provider information: 1 dentistry’s approach to patient care. Dental Board of California: Provider RP5933. Course registration number CA code: 03-5933-21001. Expires 7/31/2022. “This course meets the Dental Board of California’s requirements for Educational objectives three (3) units of continuing education.” • Identify various types of sleep-disordered breathing Endeavor Business Media • Describe the screening process for identifying sleep-disordered breathing is a nationally approved PACE program provider for FAGD/MAGD credit. • Appraise the risks of undiagnosed and untreated sleep-disordered breathing Approval does not imply acceptance • Recognize the signs and symptoms for sleep-disordered breathing in adults by any regulatory authority or AGD endorsement. • Distinguish the treatment options available for sleep-disordered breathing 11/1/2019 to 10/31/2022. Provider ID# 320452 AGD code: 730

Endeavor Business Media is designated as an approved Provider by the American Academy of Dental Hygiene, Inc. #AADHPNW (January 1, 2021-December 31, 2022). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of dental continuing education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

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In 2017, the American Dental Associa- In no way, however, is OSA limited to parasympathetic/sympathetic dysregu- tion (ADA) adopted a policy addressing overweight men. Many women, even slim lation that is very stressful to the body dentistry’s role in discovering and treat- women, have been diagnosed with OSA or and increases systemic inflammation.9 ing sleep-breathing disorders, including other types of sleep-disordered breathing, Systemic inflammation is the number one obstructive sleep apnea (OSA). In OSA, a so clinicians must be vigilant to screen factor in atherosclerosis and accelerated physical obstruction, such as the tongue every patient, regardless of age, sex, or aging.10 This is one of the ways that OSA or the pharyngeal muscles, blocks the air- body type, for airway disorders.7 contributes to illness and death. way, which interferes with breathing while the person is asleep. People with OSA have Obstructive sleep Common misdiagnosis multiple episodes of difficulty breath- apnea and snoring Often, people with sleep-disordered breathing, with too little oxygen (hypopnea) or OSA is the most common form of sleep-dis- ing are misdiagnosed with other condi- a complete lack of breathing (apnea) at ordered breathing. In OSA, a person stops tions that present with similar symptoms. night, which can severely impact health. breathing during sleep and, as a result, the According to DeWitt C. Wilkerson, DMD, The ADA policy encourages dental profes- brain experiences repeated episodes of suf- and E. Shanley Lestini, DDS, in their book, sionals to screen patients for sleep-disor- focating.3 In an attempt to get critical oxy- The Shift, the Dramatic Movement toward dered breathing and to collaborate with gen, the brain signals the person to gasp Health Centered Dentistry, children with medical physicians to manage patients for air, which is often heard as a loud snort OSA or upper airway resistance syndrome with OSA.2 The focus on the airway, which or snore. Snoring is viewed as embarrass- are often misdiagnosed with attention defi- was never part of the traditional dental ing and people are often hesitant to admit cit hyperactivity disorder (ADHD). Young school curriculum, is now a part of main- that they snore. Therefore, many people go and middle-aged adults are frequently stream dentistry. untreated and are at risk of serious health misdiagnosed with temporomandibular Dental professionals have easy access consequences. Additionally, many people joint dysfunction. Middle-aged adults with to examine their patients’ airways at every believe that simple snoring is not a signifi- OSA or upper airway resistance syndrome appointment, and so are in the perfect cant concern, but all snoring is abnormal often show signs and symptoms that mimic position to be the first to discover possible and should be considered a serious symp- dementia, challenges with memory and airway restrictions and sleep-disordered tom and possible sign of OSA.8 concentration, difficulty making decisions, breathing.3 The diagnosis of sleep-disor- The central characteristic of OSA is and depression.1 dered breathing must be made by a sleep the increased collapsibility of the upper specialist; however, many people will not airway during sleep. The restriction or Risks of untreated seek a sleep evaluation without the rec- blockage of the airway occurs during obstructive sleep apnea ommendation of another health-care pro- sleep, usually when the tongue collapses The dental professional must be aware of fessional. And this is where the dental against the soft palate and the soft palate the multiple risks of untreated OSA and professional can make an impact. collapses against the back of the throat. be able to share this information with The ADA states that approximately The result is markedly reduced or absent patients who may have no idea of the seri- 60% of Americans see a dentist annually.4 airflow from the nose or mouth. This is ous consequences they face if sleep-dis- It is estimated that 23 million Americans usually accompanied by desaturation of ordered breathing isn’t treated. suffer from OSA, with 80% of moderate to oxyhemoglobin (oxygenated blood) and Hypertension: OSA increases risk for severe cases undiagnosed.5 This means it is typically terminated by a brief micro- hypertension by 5.5 times. Multiple awak- is most likely that several people who enter arousal in which the brain rouses the enings stress the body, causing hormone our practices every day suffer from undi- sleeper, usually only partially, to signal systems to go into overdrive, resulting in agnosed airway restrictions and sleep- breathing to resume.3 The dental profes- increased blood pressure.11 disordered breathing. sional must refer to an otolaryngologist Cardiovascular disease: People who to evaluate nasal patency. suffer from OSA have a higher risk for Who is at risk for obstructive In those with severe OSA, this can hap- heart attacks, strokes, and atrial fibril- sleep apnea? pen hundreds of times a night, leading to lation. OSA disrupts the way the body This condition can strike people of any sustained reduction in oxyhemoglobin sat- receives oxygen, which makes it difficult age, including infants and children, but uration. This stresses the sleeper’s body and for the brain to control the blood flow to it is most frequently seen in men over 40, causes sleep fragmentation, often most the brain and the arteries.12 especially those who are overweight or intensely late in the sleep cycle during Type 2 diabetes: OSA affects 80% or obese. The increasing obesity rate in the slow-wave and rapid-eye-movement (REM) more people with type 2 diabetes. OSA United States is believed to be related to sleep. As a result, the patient’s sleep is alters glucose metabolism and promotes the increase in OSA.6 Too little good-qual- extremely fragmented and of poor quality.3 insulin resistance.13 ity, restful sleep can contribute to obesity, Symptoms may include snoring, Obesity: Excess weight increases the and it may be unclear which came first, pauses in breathing, and disturbed sleep. risk of developing OSA, and OSA makes the obesity or the OSA. This sleep disturbance stimulates the weight loss difficult. Additionally, OSA is

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related to insulin resistance and causes automatically trigger a referral to a sleep breathing and with TMD and cervical the release of the hormone ghrelin, which physician for evaluation and diagnosis, neck pain, which can all be related to increases cravings for sweets. Nocturnal including snoring, witnessed apnea, exces- sleep-disordered breathing. Additionally, awakenings and microarousals are con- sive daytime sleepiness, and the presence difficulty breathing in a supine position, nected to chronic cortisol release.14 of medical comorbidities such as hyper- as in the dental chair, may be a sign of Acid reflux: Up to 60% of patients tension, obesity, depression, gastroesoph- sleep-disordered breathing. who suffer from OSA also suffer from ageal reflux, diabetes, and asthma.8,23 Tongue tie: A short lingual frenum can gastroesophageal reflux. More research decrease the size of upper airway support is needed to determine the exact relation- Signs and symptoms23 by the tongue and contribute to upper ship, but studies have shown that treat- Mouth breathing: Most studies show airway collapse. ment with a CPAP can improve acid reflux that nasal breathing is ideal breathing, Chronic cough: Chronic cough due to symptoms.15 especially since the nose and the parana- gastric reflux is closely associated with OSA. Asthma: Studies confirm that OSA is sal sinuses are the primary sites in which Deviated septum: A deviation in the an independent risk factor for exacerba- our bodies produce nitric oxide, which is septum, which separates the two nos- tion of asthma. Bronchoconstriction and critical for whole-body health.24 trils, can alter airflow through the nostrils, gastroesophageal reflux have been sug- Bruxism: Studies show that nearly one reducing the effectiveness of breathing gested as mechanisms that can lead to in four people with OSA exhibit night- through the nose, resulting in sleep- worsening asthma in patients with OSA.16 time bruxism. Some researchers believe breathing difficulties. Cancer: Intermittent hypoxia has been that upper airway resistance causes an Mallampati score >2: The Mallam- implicated in the increased incidence and arousal, which increases stress through- pati score involves visual assessment of more adverse prognosis of cancer.17 out the body, leading to an increase in the distance between the tongue and the Auto and other accidents: Insuffi- the activity of the muscles of mastication, roof of the mouth, which determines the cient quantity and quality of sleep results resulting in bruxing. The movement of the amount of airway space. A higher score in fatigue, increasing the risk of falling jaw forward opens the airway and the per- predicts the risk for OSA. asleep at the wheel. People with sleep son is able to take a breath. Another the- Scalloped tongue: When the den- apnea are up to five times more likely to ory is that when the tissues of the upper tal arches are narrow, the tongue space have traffic accidents.18 airway collapse during episodes of snor- is restricted and the tongue overlaps the Depression: Depression and other ing, partial, or complete apnea, the brain teeth, resulting in indentations, or scallops, mood disorders have been found to be signals the jaw muscles to tighten, which along the lateral borders of the tongue. This common in those who experience exces- stiffens the sides of the throat, preventing indicates restricted airway space. Tongue sive daytime sleepiness.19 the collapse of the airway tissues. scallops may also appear as a result of the Fibromyalgia: Fibromyalgia is a wide- Snoring: Chronic snoring is a sign tongue being pushed forward against the spread pain and fatigue syndrome with of structural or functional pathology in teeth in an effort to open the airway. an unknown etiology. People with fibro- the airway. Skeletal profile: Maxillary and/or myalgia have a tenfold increase in sleep- Poor sleep quality and daytime mandibular skeletal underdevelopment, disordered breathing, including OSA.20 sleepiness: Multiple arousals and sleep or narrow jaws, can compromise the air- Chronic fatigue syndrome: Chronic fragmentation result in daytime sleepi- way space. fatigue syndrome is a disabling illness affect- ness, ADHD, and bedwetting in children, ing approximately 0.2% of the US popula- morning headaches, joint pain, frequent Screening guidelines tion.21 Disrupted sleep is a classic sign of trips to the bathroom, foggy thinking, According to the American Academy chronic fatigue syndrome in patients report- temporomandibular joint dysfunction, of Dental Sleep Medicine, the following ing excessive daytime sleepiness, nonrestor- muscle pain, and achy joints, among other guidelines should be followed in screen- ative sleep, difficulty falling asleep and conditions. A patient who falls asleep in ing adult dental patients for sleep-related staying asleep, and sleep disorders such as the reception room or during dental treat- breathing disorders.8 insomnia, narcolepsy, and OSA. ment may well suffer from sleep-disor- 1. Review screening questionnaires, Reduced libido: OSA has been associ- dered breathing. medical history, dental history, family ated with altered pituitary-gonadal func- Nasal congestion: Undiagnosed and history, and medications. Many medi- tion, such as decreased testosterone and untreated allergy-related and nasal air- cations may significantly impact the sexual dysfunction, manifested primarily as way-related problems, such as sinus infec- sleep schedule as well as sleep respi- erectile dysfunction and decreased libido.22 tions and deviated septum, can lead to ratory patterns.8 sleep-disordered breathing. Nasal con- 2. Record baseline blood pressure, neck cir- Dental screenings gestion and mouth breathing can signal cumference, and body mass index (BMI). The goal of dental screenings is to assess sleep-disordered breathing. 3. Evaluate oral and facial anatomic con- the patient for both sleep and awake Forward head posture: Forward ditions, including maxillary and man- symptoms. Certain criteria should head posture is associated with mouth dibular arch formation, pharyngeal

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crowding, sleep bruxism, and enamel snoring, and blood pressure, as well as Positional therapy: Special pillows erosion associated with gastroesopha- measurements of body mass, neck size, help people remain on their sides during geal reflux. age, and gender. sleep, reducing airway obstruction. 4. Visualize the posterior pharyngeal Berlin questionnaire: This ques- Tonsillectomy and adenoidectomy: wall, soft palate, uvula, and palatine tionnaire asks questions similar to the Removal of tonsils and/or adenoids if tonsils. The Mallampati score and the STOP-Bang. enlarged and contributing to airway Friedman tongue position classifica- Apps: There are now computer appli- restriction. tion are commonly used to evaluate cations that can be used on smartphones Uvulopalatopharyngoplasty (UP3): these structures.25 and other smart devices that can track Removal of excess tissue in the soft pal- 5. The primary site of upper airway snoring and risks for OSA. ate to widen the airway and allow easier obstruction occurs in the retropala- High-resolution pulse oximetry or flow of air. tal tissues, so the nose should also be heart rate variability, or a home sleep Genioglossus advancement (GGA): evaluated for possible obstructions. In test: These professional tools collect over- Recommended when the airway collapses the dental practice, we are restricted to night data to be analyzed by the dentist behind the tongue. The mandible is moved questioning patients whether they are or physician. forward, pulling the base of the tongue able to breathe well through the nose Polysomnogram: This professional muscles forward to open the airway. and if they are aware of nasal devia- test is performed in a sleep lab. Inspire hypoglossal nerve stimu- tion. The patient should be referred to Gathering all of this data will inform lator: A monitor is implanted to deliver an ear, nose, and throat physician for the examining dentist and dental hygien- mild stimulation to airway muscles and evaluation if either the nasal or pha- ist of any need to refer the patient to a move the tongue and other soft tissues ryngeal patency is compromised.8 sleep physician. away from the upper airway to enable 6. Evaluate the tongue size, position, color, improved breathing. shape, and texture. A scalloped tongue Treatment28 Maxillomandibular advancement is a highly significant sign in OSA.26 CONTINUOUS POSITIVE (MMA) surgery: Shortened maxilla or 7. Examine the temporomandibular AIRWAY PRESSURE (CPAP) mandible are lengthened and positioned joint as well as the masseter, tempo- The standard treatment for OSA is con- forward to enhance the airway. ralis, and sternocleidomastoid mus- tinuous positive airway pressure, which Maxillomandibular expansion cles. Any crepitus and pain should be involves using a device that delivers pres- (MME): This combination of orthodon- noted. There may be an association surized air through the nose, or nose and tic appliances and surgical intervention between TMJ disorders and sleep-dis- mouth, to the throat by way of a mask. That is used to enlarge the airway space and ordered breathing.27 pressure keeps the throat from collapsing increase the intraoral space for the tongue. 8. The tooth examination should include during sleep and enables normal breathing. Weight loss or bariatric surgery: angle classification, overbite and overjet, There are some people who don’t toler- Obesity may cause fatty tissue to build evaluation of midlines, crossbites, wear ate a CPAP well. For those people, there up around the throat and at the base of the facets, spacing, and crowding. Bruxism is are alternative treatments. tongue, impeding airway space. Weight a telltale sign of sleep-related breathing loss may reduce fatty tissue and result in disorder and should be a red flag when CPAP ALTERNATIVES a more open airway. you see occlusal wear facets, incisal wear, Orofacial myofunctional therapy (OMT): Tongue reduction surgery: Reduc- and mandibular and maxillary tori. OMT strengthens muscle weakness in the ing the size of the tongue may improve 9. Home sleep tests (HST) measure the mouth, tongue, and the muscles of the oro- airflow and breathing. heart rate, airflow, the apnea-hypop- pharyngeal complex. It has been shown to Buteyko training and mouth taping: nea index (AHI), oxygen saturation, reduce AHI and arousals, and to improve Breathing exercises and mouth taping are respiratory effort, and sleep position. subjective symptoms of daytime sleepiness, used to encourage nasal breathing. 10. Patient interviews that include a few sleep quality, and life quality.29 simple questions can help identify Mandibular advancement appli- Conclusion possible OSA. ance: The jaw is moved forward to As dentistry grows as a medical specialty, increase upper airway space and reduce dentists and dental hygienists are tasked Assessment tools for air resistance. with ever-expanding roles. We must study obstructive sleep apnea Nasal expiratory positive airway areas of health that we never learned in The Epworth Sleepiness Scale: This pressure (nasal EPAP): Prevents upper dental and dental hygiene school. New questionnaire can reveal how sleepy a airway collapse by creating an airtight research is being published and the stan- patient feels during waking hours and can seal of the nostrils. dard of care continues to evolve. This identify those who may be at risk for OSA. Oral pressure therapy: Application is what keeps dentistry fresh, exciting, The STOP-Bang questionnaire: of negative pressure to the upper airway and challenging. We have increasing This instrument asks about fatigue, to reposition the tongue and soft palate. opportunities to elevate our identities

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as health-care professionals, to help our 11. Dopp JM, Reichmuth KJ, Morgan BJ. Obstructive Otorhinolaryngol. 2016;20(2):145-150. patients achieve higher levels of overall sleep apnea and hypertension: mechanisms, doi:10.1055/s-0036-1579546 evaluation, and management. Curr Hypertens Rep. health, and to save lives. 24. Lundberg JO, Farkas-Szallasi T, Weitzberg E, et al. 2007;9(6):529-534. High nitric oxide production in human paranasal References 12. Parish JM, Somers VK. Obstructive sleep apnea sinuses. Nat Med. 1995;1(4):370-373. and cardiovascular disease. Mayo Clin Proc. 1. Wilkerson DC, Lestini ES. The Shift: The Dramatic 25. Friedman M, Hamilton C, Samuelson CG, et al. 2004;79(8):1036-1046. Movement Toward Health Centered Dentistry. Widiom Diagnostic value of the Friedman tongue position Publishing; 2019:117-192. 13. Pamidi S, Tasali E. Obstructive sleep apnea and type and Mallampati classification for obstructive 2 diabetes: Is there a link? Front Neurol. 2012;3:126. sleep apnea: a meta-analysis. Otolaryngol 2. Stickle, Dillon. American Dental Association Adopts doi:10.3389/fneur.2012.00126 Head Neck Surg. 2013;148(4):540-547. Policy on Dentistry’s Role in Sleep-Disordered doi:10.1177/0194599812473413 Breathing. Sleep Review. March 14, 2018. Accessed 14. Romero-Corral A, Caples SM, Lopez-Jimenez January 30, 2020. https://www.sleepreviewmag. F, Somers VK. Interactions between obesity 26. Weiss TM, Atanasov S, Calhoun KH. The association com/sleep-treatments/therapy-devices/oral- and obstructive sleep apnea: implications for of tongue scalloping with obstructive sleep apnea and appliances/american-dental-association-policy- treatment. Chest. 2010;137(3):711-719. doi:10.1378/ related sleep pathology. Otolaryngol Head Neck Surg. dentistrys-role-sleep-disordered-breathing/ chest.09-0360 2005;133(6):966-971. 3. Memon J, Manganaro SN. Obstructive sleep- 15. Jung HK, Choung RS, Talley NJ. Gastroesophageal 27. Smith MT, Wickwire EM, Grace EG, et al. Sleep disordered breathing. StatPearls. Updated May reflux disease and sleep disorders: evidence disorders and their association with laboratory pain 29, 2020. https://www.ncbi.nlm.nih.gov/books/ for a causal link and therapeutic implications. J sensitivity in temporomandibular joint disorder. Sleep. NBK441909 Neurogastroenterol Motil. 2010;16(1):22-29. 2009:32(6):779-790. doi:10.5056/jnm.2010.16.1.22 4. Health Policy Institute. The oral health care system: a 28. Calik MW. Treatments for obstructive sleep apnea. J state-by-state analysis. American Dental Association. 16. Alkhalil M, Schulman E, Getsy J. Obstructive sleep Clin Outcomes Manag. 2016;23(4):181-192. Accessed January 29, 2020. http://www.ada. apnea syndrome and asthma: What are the links? J 29. de Felício CM, da Silva Dias FV, Trawitzki LVV. org/~/media/ADA/Science%20and%20Research/ Clin Sleep Med. 2009;5(1):71-78. Obstructive sleep apnea: focus on myofunctional HPI/OralHealthCare-StateFacts/Oral-Health-Care- 17. Gozal D, Farré R, Nieto FJ. Obstructive sleep apnea therapy. Nat Sci Sleep. 2018;10:271-286. doi: System-Full-Report.ashx and cancer: epidemiologic links and theoretical 10.2147/NSS.S141132 5. American Sleep Apnea Association. Sleep apnea biological constructs. Sleep Med Rev. 2016;27:43- information for clinicians. Accessed January 55. doi:10.1016/j.smrv.2015.05.006 KATHRYN GILLIAM, BA, RDH, 30, 2020. https://www.sleepapnea.org/learn/ 18. Tregear S, Reston J, Schoelles K, Phillips B. FAAOSH, HIAOMT, is the CEO sleep-apnea-information-clinicians Obstructive sleep apnea and risk of motor vehicle and founder of PerioLinks, a consulting and speaking crash: systematic review and meta-analysis. J Clin 6. Al Lawati NM, Patel SR, Ayas NT. Epidemiology, company. She is also an oral Sleep Med. 2009;5(6):573-581. risk factors, and consequences of obstructive sleep wellness practitioner, key opinion apnea and short sleep duration. Prog Cardiovasc Dis. 19. Ejaz SM, Khawaja IS, Bhatia S, Hurwitz TD. leader, industry influencer, and 2009;51(4):285-293. Obstructive sleep apnea and depression: a author. Kathryn’s interest in the 7. Wimms A, Woehrle H, Ketheeswaran S, Ramanan review. Innov Clin Neurosci. 2011;8(8):17-25. medical side of dentistry led her D, Armitstead J. Obstructive sleep apnea in women: 20. Köseog˘lu HI˙, ˙Inanır A, Kanbay A, et al. Is to graduate twice from the Bale Doneen Preceptorship for Cardiovascular Disease Prevention. She then completed Specific issues and interventions. Biomed Res Int. there a link between obstructive sleep apnea level one of the functional oral systemic health 2016;2016:1764837. doi: 10.1155/2016/1764837 syndrome and fibromyalgia syndrome? Turk miniresidency of the Exceptional Dental Courses, and, in . 2017;18(2):40‐46. doi:10.5152/ 8. Levine M, Bennett KM, Cantwell MK, Postol K, Thorac J 2018, she earned a fellowship in the American Academy Schwartz DB. Dental sleep medicine standards TurkThoracJ.2017.16036 for Oral Systemic Health. Kathryn earned a certification in for screening, treating, and managing adults with 21. Jackson ML, Bruck D. Sleep abnormalities in chronic biological dental hygiene from both the International sleep-related breathing disorders. J Dent Sleep Med. fatigue syndrome/myalgic encephalomyelitis: a Academy of Biological Dentistry and Medicine and the 2018;5(3):61-68. doi: 10.15331/jdsm.7030 review. J Clin Sleep Med. 2012;8(6):719‐728. International Academy of Oral Medicine and Toxicology in 2020. Kathryn is a faculty member and dental hygiene 9. Mansukhani MP, Kara T, Caples S, Somers VK. doi:10.5664/jcsm.2276 specialty coach for the Productive Dentist Academy. She 22. Kim SD, Cho K-S. Obstructive sleep apnea and Chemoreflexes, sleep apnea, and sympathetic also serves on the peer-review board for the Dental dysregulation. Curr Hypertens Rep. 2014;16(9):476. testosterone deficiency. World J Mens Health. Academy for Continuing Education and has published doi:10.1007/s11906-014-0476-2 2018;37(1):12‐18. doi:10.5534/wjmh.180017 multiple articles and continuing education courses. 10. Sanada F, Taniyama Y, Muratsu J, et al. Source of 23. Pinto JA, Ribeiro DK, da Silva Cavallini AF, et chronic inflammation in aging. Front Cardiovasc Med. al. Comorbidities associated with obstructive 2018;5:12. doi:10.3389/fcvm.2018.00012 sleep apnea: a retrospective study. Int Arch

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Notes

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QUESTIONS

1. In 2017, the American Dental Association 6. Which is the least common type of sleep- 12. Obstructive sleep apnea comorbidities adopted a policy regarding dentistry’s role disordered breathing? include: in: A. Upper airway resistance syndrome A. GERD A. The use of mercury in B. Obstructive sleep apnea B. Bruxism amalgam restorations C. Central sleep apnea C. Depression Discovering and treating sleep- B. D. Snoring D. All of the above disordered breathing C. The overuse of systemic antibiotics 7. The central characteristic of obstructive sleep 13. Children with sleep-disordered breathing apnea is: are often misdiagnosed with: D. All of the above A. Snoring A. Malocclusion 2. Obstructive sleep apnea is: B. Collapsibility of the upper airway B. ADHD A disorder of the digestive system A. C. Gasping for breath C. Allergies A condition in which people B. D. None of the above D. None of the above are unable to sleep C. A disorder of the reproductive system 8. Desaturation of oxyhemoglobin refers to: 14. Young and middle-aged adults with sleep-disordered breathing are often D. A condition in which people stop A. Reduction of the blood oxygen level misdiagnosed with: breathing during sleep B. Increase of the blood oxygen level Reduction of red blood cells A. Asthma 3. How many Americans are believed to have C. B. Temporomandibular joint dysfunction obstructive sleep apnea? D. None of the above C. Hypochondria A. 10 million 9. In those people with severe sleep apnea: D. All of the above B. 18 million A. Desaturation does not occur 15. Middle-aged adults and older adults with C. 23 million B. Desaturation rarely occurs sleep-disordered breathing are often D. 100 million Desaturation is not a concern C. misdiagnosed with: D. None of the above 4. Dental professionals must be vigilant to A. Dementia screen which category of patients for OSA? 10. Multiple arousals during sleep lead to: B. Bell’s palsy Men A. A. Reduction in oxygenated blood C. Pneumonia Women B. B. Central nervous system dysregulation D. None of the above C. Children Increased systemic inflammation C. 16. How much greater risk for hypertension D. All of the above D. All of the above does untreated obstructive sleep apnea 5. What causes gasping, snorting, or snoring 11. Left untreated, obstructive sleep apnea can carry? during sleep? lead to all of the following except: A. 2.5X In an attempt to get oxygen, the A. A. Acne B. 5.5X brain signals the body to gasp. B. Hypertension C. 7.5X B. Loose tissues in the throat vibrate Type 2 diabetes D. None of the above when air is forcefully inspired. C. D. Weight gain C. These sounds can occur as a result of air 17. Untreated obstructive sleep apnea caries a squeezing through a narrowed airway. risk of developing: D. All of the above A. Diabetes B. Cancer C. Heart attack D. All of the above

56 DentalAcademyofCE.com ONLINE COMPLETION QUICK ACCESS code 21001 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

QUESTIONS QUESTIONS

18. Which of the following signs/symptoms 23. When screening for obstructive sleep 27. Which of the following screening methods is/are associated with sleep-disordered apnea, which tongue abnormality would be can be used to detect possible sleep- breathing? a sign? disordered breathing? A. Frequent migraine A. Fissured A. Computer apps that track snoring B. Mouth breathing B. Black hairy B. Home sleep tests C. Chronic bronchitis C. Scalloped C. High-resolution pulse oximetry D. All of the above D. Geographic or heart rate variability D. All of the above 19. Which of the following signs/symptoms 24. Monitoring vital signs at every dental is/are associated with sleep-disordered appointment can illuminate which potential 28. Which treatment for severe obstructive breathing? sign of obstructive sleep apnea? sleep apnea is considered the first choice? A. Deviated septum A. Elevated temperature A. Continuous positive airway pressure B. Nasal congestion B. Elevated blood pressure B. Tonsillectomy C. Chronic cough C. Unexplained weight gain C. Mandibular advancement device D. All of the above D. All of the above D. Mouth taping

20. Which of the following conditions should be 25. Signs a patient may have sleep-disordered 29. Which of the following is not an alternative evaluated when screening for obstructive breathing include: for CPAP? sleep apnea? A. Difficulty breathing in supine position A. Nasal expiratory positive airway pressure A. Maxillary and mandibular arch formation B. Falling asleep during dental treatment B. Positional therapy B. Sleep bruxism C. Nasal congestion and mouth breathing C. Guided meditation C. Enamel erosion D. All of the above D. Tongue reduction surgery D. All of the above 26. Screening questionnaires for obstructive 30. Which of the following represents a shift in 21. Red-flag telltale signs of sleep-disordered sleep apnea include all of the following dentistry’s approach to patient care? breathing include: except: A. Focus on importance of A. Wear facets A. STOP-Bang nutrition and exercise B. Incisal wear B. Epworth Sleepiness Scale B. Focus on the central role of airway C. Mandibular and maxillary tori C. Mallampati score and breathing disorders D. All of the above D. Berlin C. Focus on teamwork and communication D. All of the above 22. Who can evaluate for nasal and pharyngeal patency? A. Dentist B. Dental hygienist C. Otolaryngologist D. None of the above

DentalAcademyofCE.com 57 PUBLICATION DATE: MARCH 2021 ANSWER SHEET EXPIRATION DATE: FEBRUARY 2024

Breathless: Oral signs of a silent epidemic

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Educational Objectives Mail/fax completed answer sheet to: 1. Identify various types of sleep-disordered breathing Endeavor Business Media Attn: Dental Division 2. Describe the screening process for identifying sleep-disordered breathing 7666 E. 61st St. Suite 230, Tulsa, OK 74133 3. Appraise the risks of undiagnosed and untreated sleep-disordered breathing Fax: (918) 831-9804 4. Recognize the signs and symptoms for sleep-disordered breathing in adults 5. Distinguish the treatment options available for sleep-disordered breathing Payment of $59 is enclosed. Make check payable to Endeavor Business Media Course Evaluation 1. Were the individual course objectives met? If paying by credit card, please complete the following: Objective #1: Yes No Objective #3: Yes No Objective #5: Yes No MC Visa AmEx Discover Objective #2: Yes No Objective #4: Yes No Acct. number:______

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Exp. date: ______CVC #:______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Billing address:______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 ______4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Charges on your statement will show up as Endeavor. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 6. Please rate the author’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 1. 16. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 2. 17. 9. Please rate the usefulness of the references. 5 4 3 2 1 0 3. 18. 10. Do you feel that the references were adequate? Yes No 4. 19. 11. Would you take a similar course on a different topic? Yes No 5. 20. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 6. 21. 7. 22. 13. Was there any subject matter you found confusing? Please describe. 8. 23.

14. How long did it take you to complete this course? 9. 24. 10. 25. 15. What additional dental continuing education topics would you like to see? 11. 26. 12. 27. 13. 28. 14. 29. 15. 30. AGD code: 730

EXAM INSTRUCTIONS PROVIDER INFORMATION Endeavor Business Media is designated as an approved provider by the American Academy of Dental All questions have only one answer. If mailed or faxed, grading of this examination is done manually. Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Hygiene Inc. #AADHPNW (January 1, 2021 - December 31, 2022). Approval does not imply acceptance Participants will receive confirmation of passing by receipt of a Verification of Participation form. The form Dental Association to assist dental professionals in identifying quality providers of continuing dental by a state or provincial board of dentistry. Licensee should maintain this document in the event of an audit. will be mailed within two weeks after receipt of an examination. education. ADA CERP neither approves nor endorses individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns about a CE provider may be directed to the RECORD KEEPING COURSE EVALUATION AND FEEDBACK provider or to ADA CERP at ada.org/gotocerp. Endeavor Business Media maintains records of your successful completion of any exam for a minimum We encourage participant feedback. Complete the evaluation above and e-mail additional feedback to Endeavor Business Media is designated as an approved PACE program provider by the Academy of of six years. Please contact our offices for a copy of your CE credits report. This report, which will list all Aileen Southerland ([email protected]) and Laura Winfield ([email protected]). General Dentistry. The formal continuing dental education programs of this program provider are accepted credits earned to date, will be generated and mailed to you within five business days of receipt. by the AGD for fellowship, mastership, and membership maintenance credit. Approval does not imply COURSE CREDITS AND COST acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval CANCELLATION AND REFUND POLICY All participants scoring 70% or higher on the examination will receive a verification form for three (3) extends from 11/1/2019 to 10/31/2022. Provider ID# 320452. AGD code: 730. Participants who are not 100% satisfied can request a refund by contacting Endeavor Business Media continuing education (CE) credits. Participants are urged to contact their state dental boards for CE in writing. requirements. The cost for courses ranges from $20 to $110. Dental Board of California: Provider RP5933. Course registration number CA code: 03-5933-21001. Expires 7/31/2022. “This course meets the Dental Board of California’s requirements for three (3) units IMAGE AUTHENTICITY of continuing education.” The images in this educational activity have not been altered. © 2021 Academy of Dental Therapeutics and Stomatology, a division of Endeavor Business Media CUSTOMER SERVICE | CALL (800) 633-1681