Can Orthodontists Diagnose Sleep Apnea?

Orthodontists are specialists in straightening teeth and fixing bites. As doctors, we are always looking for the best ways to give our patients the most attractive, healthy smiles possible. If there is a treatment that is better, faster, or less expensive, we want to provide that treatment. At the same time, we have an obligation not to imply that we can prevent or cure disease if there is no proof supporting that claim. Doctors also have a responsibility to make sure the treatment we provide does not harm our patients, now nor in the future. An important part of being a doctor is being able to evaluate the science behind various treatment approaches and not merely be swayed by clever marketing or popular trends. For this reason, all orthodontic specialists learn to conduct and interpret research as part of their training.

Is There a Relationship Between Orthodontics and Obstructive Sleep Apnea?
One area of medicine that has been of particular interested to orthodontists in the past two decades is Obstructive Sleep Apnea (OSA). Because the teeth are so close to the nasal cavity, tongue, and throat, it is not surprising that some have suggested there may be a relationship between the position of the teeth and the prevalence of this disorder. If it could be proven that some orthodontic techniques either prevent or cure OSA, we would want to provide that treatment. Additionally, if we knew that certain techniques cause or worsen the condition, we would want to avoid those. For these reasons, the orthodontic specialty (through the American Association of Orthodontists) performed a two-year review of over 4,000 scientific studies to determine what, if any relationship exists between orthodontics and OSA. The results of this study were published in 2019 and are the basis for my four blog posts addressing the relationship between orthodontics and sleep apnea. (By the way, I am not an expert on OSA. I am merely reporting the findings of the AAO task force that WAS comprised of experts, so please don’t kill the messenger.)

Physicians Use Sleep Studies to Diagnose Obstructive Sleep Apnea
Sleep studies, officially known as polysomnography, examine a complex array of variables that determine whether or not a patient has OSA and how severe their condition is if they do. During a sleep study, a physician evaluates respiration, heart rate, brain waves, body movements, and the level of oxygen in the blood. It is a very thorough, involved examination. The results of the study are reported in terms of “events” per hour that interrupt sleep (the AHI or Apnea-Hypopnea Index number). Although physicians are interested in where the obstruction is occurring, they do not diagnose OSA by evaluating the size of the airway. Sleep apnea is caused by a collapse of the airway. This collapse is affected by many factors including airway tonicity, innervation, adjacent structures, and size. It is important to note that size is only one of many factors. Many patients with OSA have large airways that still collapse. Many people have small airways that never collapse and therefore have no sleep issues.

Orthodontists Can “Sort Of” Measure the Size of the Airway
Around the year 2000, a new kind of x-ray machine became available to orthodontists. It is called Cone Beam Computed Tomography (CBCT). Unlike previous dental x-rays, CBCT radiographs provide 3-D representations of the teeth, bone, and structures containing cartilage (like the airway). Using amazing software, orthodontists can evaluate the position of the teeth in new ways that allow for better orthodontic care. The software also allows doctors to visualize the airway. Research shows however that measurements taken from these images of the airway exhibit extreme variability due to differences in posture, patient positioning, function (i.e. swallowing, breathing, etc.), and examiner variation. Even if CBCT images of the airway do reveal constrictions, they do not provide a diagnosis of OSA as they are merely a static view of a dynamic (constantly changing) system and only reveal airway size. Although some have suggested that x-rays can at least be used to evaluate the risk of OSA, there have been multiple recent studies refuting the reliability of using x-rays for that purpose.

Orthodontists are Not Qualified to Diagnose Obstructive Sleep Apnea
The only currently accepted way to diagnose OSA is using polysomnography. Orthodontists are not trained to order nor interpret these sleep studies. Sleep doctors do not measure the size of the airway to diagnose OSA and neither should dental professionals.

Orthodontists Can Screen Patients for Sleep Apnea and Refer Those at Risk
There ARE studies showing that there is a higher percentage of OSA patients among those who seek orthodontic care than in the general population. This makes sense as breathing problems can cause some kinds of malocclusion (conversely, there is no evidence that malocclusions cause sleep issues). Since there is a higher percentage of OSA patients who seek orthodontic treatment, screening patients to determine if they should be evaluated by a sleep physician makes sense. In our office, we screen every patient for risk factors related to obstructive sleep apnea. If we identify a patient at risk, we promptly refer them to a sleep doctor for evaluation and treatment.

The Role of the Orthodontist in the Treatment of Sleep Apnea
At Jorgensen Orthodontics, we recognize our role in the treatment of sleep apnea. We are not experts in OSA, but we are experts in orthodontics, and we want to provide the best care to our patients. In accordance with the position paper of the American Association of Orthodontists, we do not believe that we can diagnose, prevent, or treat sleep apnea, nor do we cause it. We do feel that we can screen our patients to identify those who are at risk and refer them to qualified sleep physicians who have the appropriate tools to diagnose and treat their conditions. If a physician feels that a patient would benefit from orthodontic treatment, we can provide that service.

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the Westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa. Dr. Jorgensen’s 29 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog is for informational purposes only and is provided to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.