Snoring and sleep disorders: A dental approach to a major public health issue

Almost two million people in Spain show symptoms of SA requiring treatment, but only 5% are conclusively diagnosed. Following almost a decade of research, in 2009 the Snoring and Sleep Apnoea Diagnosis and Treatment Unit was opened in the UB's Josep Finestres Foundation-Dental Clinic (Bellvitge Health Sciences Campus). The specialized unit is devoted to the study and treatment of respiratory sleep disorders from a novel perspective that places dentists at the centre of research, diagnosis and treatment. The unit is formed by Maribel Pascual, qualified in medicine and surgery and a specialist in stomatology, and the qualified dental physicians Eva Willaert and Lluís Nogués, lecturers at the Department of Dentistry and Stomatology of the UB's Faculty of Dentistry, and experts in dental prosthetics and craniomandibular dysfunction for the UB-specific master's degree in Occlusion and Oral Rehabilitation directed by Dr. Joan Salsench, Dr. Maria Peraire and Dr. Jordi Samsó from the University of Barcelona (UB).

The team was created in 2000 through an initial collaboration agreement between the experts Maribel Pascual and Carme Monasterio (director of the Sleep Unit of the Pneumology Service at Bellvitge University Hospital) and was the first in Spain to introduce the study of respiratory sleep disorders, sleep apnoea and treatment with mandibular advancement devices (MAD) at postgraduate level for the master's degree they contribute to as experts.

A disease largely unknown among the public

Maribel Pascual explains that, "diagnosis and treatment of sleep apnoea are placing a strain on the healthcare system and generating substantial expense. As dentists, we can bring a new therapeutic perspective to deal with the complex symptoms involved, which can be exhibited in the respiratory apparatus but treated through the stomatognathic system, that is, the oral cavity, so we can add to the treatment options provided by other experts (pneumologists, neurophysiologists, maxillofacial surgeons, dieticians, etc). According to the National Consensus Document on Sleep Apnoea, drawn up by the Spanish Sleep and Breathing Group, patients with SA are between seven and eight times more likely to suffer traffic or workplace accidents than the general population.

Excess weight, alcohol consumption, smoking, polymedication, nasal obstruction, menopause and unhealthy lifestyle habits in general have a negative impact on health and the sleep cycle. "As healthcare professionals, our obligation is to encourage people to correct habits that are harmful to their health to improve sleep hygiene and quality of life. We must use our knowledge to guarantee effective medical treatment for patients. Professionals with responsibility for the health and safety of others, such as ourselves, or chauffeurs and pilots, for example, know that our work is helping to save lives and to save companies money," says Maribel Pascual. As Eva Willaert explains, "In the case of snoring, the model has changed completely: before we thought it was a sign of sleeping well, but snoring can be the first sign of respiratory difficulties during sleep. Statistics show that 60% of men over 50 and 40% of women in the same age group snore. Not everyone that snores develops SA, but snoring can lead to other health conditions and it is always worth reviewing clinical histories."

Dentists, the key to early diagnosis

Dentists play a vital role in detecting diseases associated with dental health and facilitating earlier and less costly treatment of snoring and SA. In the specific case of sleep apnoea, failure to treat the disorder in its early stages can increase the cost of subsequent treatment two- or threefold. Lluís Nogués believes that, "dentistry has an increasing presence in the field of respiratory diseases, but hospital Sleep Units rarely have dentists as part of their teams. When dental professionals are required, hospitals seek the help of external partners to ensure the best service for their patients." Nogués goes on to explain that, "At present, dental sleep medicine is a highly specialized area of study and requires specific postgraduate training. In the university sphere, we are pioneers not only in the teaching of this specialism but also in the care setting. Nevertheless, in Spain, the dental profession has become synonymous with business, and we must fight against this image and seek ways to work more closely with other specialists in the public healthcare system."

Conducting research to improve quality of life

The standard diagnostic test for respiratory sleep disorders is polysomnography, which records respiratory flow, heart rate, blood oxygen and sleep phases, etc. The most common treatment for snoring and SA until recently was continuous positive airway pressure (CPAP), administered using a device consisting of a nose piece or full mask that supplies a constant air pressure during sleep. A newer alternative, the mandibular advancement device (MAD), alters certain characteristics of the upper airways, leading to improvements in people affected by snoring and by mild and moderate cases of SA, making it the preferred treatment option for both disorders. MAD can also be used intermittently to aid or replace CPAP if this option is rejected or due to other considerations such as travel or social commitments.

The Snoring and Sleep Apnoea Diagnosis and Treatment Unit, which receives referrals from the public healthcare system (Bellvitge University Hospital, Hospital Clínic, Hospital del Mar, Hospital de Viladecans, Hospital de Terrassa, etc.), also applies diagnostic techniques (imaging, polygraphs, etc.) to potential SA patients to establish the best course of treatment in each case or to identify the appropriate specialist unit for referral. As such, it functions essentially as a screening unit."Our main mission is to assess the patient as thoroughly as possible," says Maribel Pascual. "As dentists, we are in the best position to detect cases that have not been diagnosed. In lower-risk patients, MAD can be useful for reducing the symptoms of the disease and preventing further development, but the devices must be tailored to each case to match the specific clinical diagnosis."

The unit conducts exhaustive follow-up of each patient and their symptoms and has also achieved recognition for its research, in particular "for studies published in prestigious dentistry journals on the impact of MAD and the possible side effects appearing in the mouth, which are often extremely minor, provided that patients are monitored thoroughly," says Eva Willaert, who explains that, "We have also set up a research area that focuses on the quality of life of patients fitted with MAD, which are among the most recent treatments to emerge in the field of dental health." As Maribel Pascual explains, "in ten years of clinical experience we have also observed that certain prosthetic dental treatments can aggravate snoring and SA in some patients."