Should dentists routinely screen for sleep apnea?

Should Dentists Routinely Screen for Sleep Apnea?

Yes, dentists should routinely screen for obstructive sleep apnea (OSA) as part of their clinical practice, given their unique position to identify at-risk patients during regular dental visits, though formal diagnosis must always be confirmed by a sleep physician. 1

Rationale for Dental Screening

Strategic Positioning of Dentists

• Approximately 61% of Portuguese adults visit a dentist at least once annually for professional oral hygiene or other procedures, placing dentists in an ideal position to perform OSA screening. 1
• Dentists routinely examine the oral cavity, oropharynx, and craniofacial structures—anatomical areas directly relevant to OSA pathophysiology. 1, 2
• OSA remains severely underdiagnosed, with an estimated 80% of cases undetected, representing a massive public health and economic burden. 1

Evidence Supporting Dental Involvement

• Multiple international guidelines, including consensus statements from Portuguese scientific societies (Portuguese Society of Pulmonology, Portuguese Society of Stomatology and Dental Medicine, Portuguese Dental Association), explicitly recommend that dentists participate in OSA screening. 1
• The American Academy of Dental Sleep Medicine advocates that qualified dentists should have special training or experience to deliver informed care in dental sleep medicine. 1
• Dentists can identify key anatomical risk factors including neck circumference >40cm, large tongue size, Mallampati Class 3 or 4 scores, and deep palatal vault—all independent predictors of high OSA risk. 2

Screening Protocol for Dentists

Clinical Assessment Components

• Use validated screening questionnaires (such as STOP-BANG) to identify high-risk patients during routine dental visits. 1, 2
• Evaluate craniofacial and upper airway abnormalities including micrognathia, retrognathia, maxillary arch constriction, and temporomandibular disorders. 1, 2
• Measure neck circumference, assess body mass index, and document patient age and gender as part of risk stratification. 2
• Examine oral cavity for Mallampati score (uvula visibility), tongue size relative to oral cavity, and depth of palatal vault. 2

Critical Limitation: Diagnosis Requires Physician Confirmation

• Dentists should screen for OSA but diagnosis and treatment efficacy must always be verified by sleep physicians, even when screening and oral appliance selection are performed by qualified dentists. 1
• Formal diagnosis requires polysomnography (PSG) or home sleep apnea testing (HSAT) prescribed by a sleep physician. 1
• The multidisciplinary team must include the qualified dentist, sleep unit, and sleep physician as recommended by international guidelines. 1

Contrast with Primary Care Screening Recommendations

USPSTF Position on Routine Screening

• The U.S. Preventive Services Task Force (USPSTF) concluded in 2017 that current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults (Grade I recommendation). 1
• The USPSTF found inadequate evidence on screening tools to accurately detect persons in asymptomatic populations who should receive further testing. 1
• Most primary care clinicians do not routinely screen for OSA, with only 20% of patients with sleep-related symptoms spontaneously reporting symptoms to their clinician. 1

Why Dental Screening Differs from General Population Screening

• The dental screening context differs fundamentally because dentists examine anatomical structures directly relevant to OSA during every routine visit, making opportunistic screening more feasible and targeted. 1, 2
• Dentists can identify specific craniofacial risk factors (retrognathia, micrognathia, narrow maxilla) that primary care physicians typically do not assess. 2
• The dental visit provides a natural opportunity for anatomical assessment without requiring additional appointments or resources. 1

Implementation Framework

Required Training and Competence

• Dentists should be educated according to American Academy of Dental Sleep Medicine-defined requirements to be a "Qualified Dentist" in dental sleep medicine. 1
• Special training or experience is required to deliver informed care, though specific criteria vary by country. 1
• In Portugal, competence in dental sleep medicine was framed in December 2021, though specific qualification criteria remain under development. 1

Referral Pathway

• When screening identifies high-risk patients, dentists must refer to sleep physicians for diagnostic sleep studies (PSG or HSAT) before any treatment decisions. 1
• The sleep physician prescribes overnight polysomnography or home sleep apnea testing to collect objective data determining if the patient has sleep-disordered breathing. 1
• Diagnosis severity is determined using the Apnea-Hypopnea Index (AHI): mild OSA (5 ≤ AHI < 15/h), moderate OSA (15 ≤ AHI < 30/h), and severe OSA (AHI ≥ 30/h). 1

Treatment Role After Diagnosis

• Once OSA is diagnosed by a sleep physician, qualified dentists can provide mandibular advancement devices (MADs) for patients with mild to moderate OSA or those intolerant to CPAP therapy. 1, 3
• Oral appliances are recommended by the American Academy of Sleep Medicine for primary snoring and mild to moderate OSA. 3, 4
• Follow-up sleep testing with the oral appliance in place after final adjustments is required to ensure satisfactory therapeutic benefit. 1

Clinical Impact and Public Health Considerations

Morbidity and Mortality Implications

• Observational studies report associations between severe OSA and mortality risk, though well-controlled trials demonstrating mortality improvement with treatment are lacking. 1
• OSA is associated with hypertension, coronary disease, stroke, dysrhythmias, diabetes, and increased risk of motor vehicle or workplace accidents. 1
• Among employees being actively treated for OSA, a 73% reduction in preventable driving accidents was identified. 1

Economic Burden

• Direct costs of OSA relate to comorbidities including cardiovascular disease, while indirect costs include decreased work productivity, reduced quality of life, and interpersonal relationship stress. 1
• The economic burden of sleep-disordered breathing in the United States is estimated in billions of dollars. 1
• The healthcare system should focus on preventing and early diagnosing sleep-disordered breathing rather than acute problem-solving, which carries much higher economic and social costs. 1

Common Pitfalls to Avoid

• Never attempt to diagnose OSA based solely on dental screening—always refer to sleep physicians for formal diagnostic testing. 1
• Do not confuse screening capability with diagnostic authority; the dentist's role is identification and referral, not independent diagnosis. 1
• Avoid providing oral appliance therapy without confirmed OSA diagnosis from polysomnography or home sleep testing interpreted by a sleep physician. 1
• Do not neglect follow-up sleep testing after oral appliance placement, as this is essential to verify treatment efficacy. 1
• Recognize that barriers to screening cited by clinicians include uncertainty about identification methods and follow-up protocols—address these through proper training. 1