Correspondence

Sleep-Disordered Breathing

N Engl J Med 1993; 329:1429-1430November 4, 1993

Article

To the Editor:

I would like to add several comments to the article on sleep-disordered breathing among middle-aged adults (April 29 issue)1 and the accompanying editorial2.

Dentists represent an untapped resource for screening people at risk for primary snoring and obstructive sleep apnea. It would be relatively simple to ask patients about their sleep habits during routine dental visits. Because of media publicity about dental appliances that help control snoring, many people are already looking to dentists for assistance with this problem. In addition, dentists are familiar with oral structures. They are often the first to identify and assume responsibility for referral or treatment of people with abnormalities of both the hard and soft tissues of the oral cavity and pharynx.

Neither Young et al. nor Phillipson discusses the potential usefulness of dental appliances in the management of obstructive sleep apnea. High rates of acceptance by patients and effectiveness have been reported, especially in the management of mild-to-moderate disease3-5. These dental appliances are small plastic intraoral devices similar to orthodontic appliances or sports mouthguards. They are worn during sleep and may help maintain patency of the airway by holding the tongue forward, advancing the mandible, or supporting the soft palate. The use of intraoral appliances to treat sleep apnea is a new area and requires further investigation. The appliances should be evaluated alone for the initial phase of treatment and in combination with other treatments for later stages.

Laurence I. Barsh, D.M.D.
21 Bay State Rd., Boston, MA 02215

5 References

1. 1

   Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-1235
   Full Text | Web of Science | Medline

2. 2

   Phillipson EA. Sleep apnea -- a major public health problem. N Engl J Med 1993;328:1271-1273
   Full Text | Web of Science | Medline

3. 3

   Bonham PE, Currier GF, Orr WC, Othman J, Nanda RS. The effect of a modified functional appliance on obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1988;94:384-392
   CrossRef | Web of Science | Medline

4. 4

   Schmidt-Nowara WW, Meade TE, Hays MB. Treatment of snoring and obstructive sleep apnea with a dental orthosis. Chest 1991;99:1378-1385
   CrossRef | Web of Science | Medline

5. 5

   Cartwright R, Stefoski D, Caldarelli D, et al. Toward a treatment logic for sleep apnea: the place of the tongue retaining device. Behav Res Ther 1988;26:121-126
   CrossRef | Web of Science | Medline

To the Editor:

It would have been interesting if Young et al. had included the cephalometric measurements of their patients' maxillofacial bone structures and soft palates among the variables considered. Bacon et al.1 have reported that patients with sleep apnea have the following features: a shortened cranial base; posterior facial compression, with reduction of the bony pharynx; vertical elongation of the lower face, with a retruded chin and tongue; and a lengthened soft palate.

Abel Garcia
Universidad de Santiago, 15075 Santiago de Compostela, Spain

1 References

1. 1

   Bacon WH, Turlot JC, Krieger J, Stierle JL. Cephalometric evaluation of pharyngeal obstructive factors in patients with sleep apneas syndrome. Angle Orthod 1990;60:115-121
   Web of Science | Medline

To the Editor:

I am concerned about the fate of the people in the study sample who were discovered to have sleep-disordered breathing; I would like to know whether any steps were taken to inform them about the dangers of untreated sleep apnea, the possibilities for treatment, or the risk of difficult airway management during surgery or other procedures.

Jerry Halberstadt
New Technology Publishing, Cambridge, MA 02139-9183

Author/Editor Response

The authors reply:

To the Editor: The commentaries on our report on sleep apnea in the general adult population draw attention to the pressing clinical issue of who should be evaluated and treated for sleep apnea.

Identifying risk factors with a high positive predictive value (the probability of truly having the disease, given that the risk factor is present) is vital to formulating recommendations about screening and referral. Snoring and cephalometric abnormalities, strongly associated with sleep apnea in clinic populations, hold promise as screening predictors. However, because predictive value is influenced by the characteristics of the population to be screened, the potential usefulness of these and other risk factors for screening the general population cannot be inferred from clinic-based data.

We have obtained, but not yet analyzed, cephalometric radiographs for our sample. However, we were able to estimate the predictive value of large neck girth in combination with habitual snoring in the general population. As shown in Table 1Table 1Probability of Sleep Apnea (Apnea-Hypopnea Score, ≥ 15) among Habitual Snorers, According to Neck-Girth Quartile., a woman with large neck girth who habitually snored would have a 14 percent probability of having sleep apnea; for a man, the probability would be 31 percent. The “prescreening” prevalence of sleep apnea is 4 percent among women and 9 percent among men1; thus, knowledge about neck girth and snoring is clearly useful in identifying people likely to have sleep apnea. If cephalometric measurements are found to add significantly to the predictive value, screening at routine dental visits, as suggested by Dr. Barsh, could indeed play a key part in the detection of sleep apnea.

At present, the consequences of untreated mild or asymptomatic sleep apnea are unknown. Our subjects were advised to consult their physicians, regardless of their apnea-hypopnea scores, if they had symptoms. Data from follow-up studies of our sample will help determine what degree of sleep-disordered breathing is of clinical importance and warrants treatment.

Terry Young, Ph.D.
Mari Palta, Ph.D.
M. Safwan Badr, M.D.
University of Wisconsin-Madison, Madison, WI 53705

1 References

1. 1

   Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-1235
   Full Text | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   M. Safwan Badr, Jason H. Mateika. 2011. Gender differences in sleep-disordered breathing. , 176-191.
   CrossRef

2. 2

   Peter Chedraui, Faustino R. Pérez-López, Marcela Mendoza, María L. Leimberg, María A. Martínez, Varinia Vallarino, Luis Hidalgo. (2010) Factors related to increased daytime sleepiness during the menopausal transition as evaluated by the Epworth Sleepiness Scale. Maturitas 65:1, 75-80
   CrossRef

3. 3

   M. Safwan Badr, James A. Rowley. 2006. Upper Airway Mechanics. .
   CrossRef

4. 4

   Yasir Tashkandi, M. Safwan Badr, James A. Rowley. (2005) Determinants of the apnea index in a sleep center population. Sleep and Breathing 9:4, 181-186
   CrossRef

5. 5

   Daniel I Loube, Alicia A Loube, Merrill M Mitler. (1994) Weight loss for obstructive sleep apnea: The optimal therapy for obese patients. Journal of the American Dietetic Association 94:11, 1291-1295
   CrossRef