What You Don't Really Need To Know, But…

Question 1

What are the nighttime symptoms of insomnia?

Answer 1

Long sleep latency
Sleep maintenance difficulty
Difficulty returning to sleep
Short sleep duration
Poor sleep quality
Early morning awakening

Question 2

What are the daytime symptoms of insomnia?

Answer 2

Fatigue and somatic symptoms
Cognitive difficulty
Affective symptoms (depression, anxiety)
Distressed, impaired
Seeking help
Self treatment (alcohol, OTC meds)
Limitation of daytime activity (attempt not to to do things that will "push the sleep away")

Question 3

What is the difference between sleep deprivation and insomnia?

Answer 3

Sleep deprivation: adequate ability to sleep, inadequate opportunity
Insomnia: inadequate ability to sleep, adequate opportunity

Question 4

What is the prevalence of insomnia?

Answer 4

30% of population has insomnia
10% meet diagnostic criteria (truly disabling)
50% of patients under clinical care have sleep disruption (caused by the other problem)

Question 5

What percentage of patients with chronic insomnia have a mental disorder?

Answer 5

Half. This is bilateral (i.e. half of psychiatric disorder patients have a sleep disorder and half of sleep disorder patients have a psychiatric disorder).

Question 6

What is delayed sleep phase syndrome (DSPS)?

Answer 6

Most common in adolescents/young adults. They cannot fall asleep until 2 or 3 a.m. and then can’t wake up at normal social hours (11 or noon). Their sleep is solid and healthy if they are allowed to sleep.

Question 7

What percentage of people with insomnia have primary insomnia?

Answer 7

About 1 in 4 (22%).

Question 8

What percentage of people with insomnia have DSPS?

Answer 8

7%

Question 9

What percentage of people with insomnia have OSA?

Answer 9

6%

Question 10

What percentage of people with insomnia have a medical disorder (not a sleep disorder)?

Answer 10

4%

Question 11

What is the incidence of depression in patients with insomnia?

Answer 11

16% compared to 4% in patients without insomnia (4 times higher rate of depression)

Question 12

What is the incidence of anxiety in patients with insomnia?

Answer 12

About double that of patients without insomnia (14% to 7%)

Question 13

What is the incidence of alcohol abuse in patients with insomnia?

Answer 13

About double that of people without insomnia (because some people with insomnia use alcohol to help them sleep)

Question 14

What is the incidence of drug abuse in patients with insomnia?

Answer 14

About 5 times higher than in people without insomnia (1% to 5%) because some people with insomnia use drugs to help them sleep

Question 15

What is the most-prescribed drug for insomnia?

Answer 15

Trazadone. Second is Ambien.

Question 16

What are the implications of insomnia in sleep dentistry?

Answer 16

OAT may worsen or be perceived as worsening insomnia
Side effects of OAT may present as insomnia, even if it is not the case
Sleep deprivation may be implicated as a side effect of OAT
FACT: an underlying and unrecognized or poorly managed medical or psychiatric disorder may cause insomnia and the blame placed on the OAT

Question 17

Sleep dentistry is part of a triangle of possible etiologies in patients with sleep disorders. What are the three points of the triangle?

Answer 17

OSA (sleep dentistry/OAT), psychiatric/medical disorders, and insomnia. If any of the points is not well-treated, blame may be placed/implicated on the other points.

Question 18

What is advanced sleep phase syndrome?

Answer 18

Common in the elderly (≥65)
Difficulty sleeping beyond 3-4 a.m.
Sleep onset time routinely no later than 8 p.m.

Question 19

What is shift work sleep disorder?

Answer 19

Chronic desynchronization of internal circadian and external time cues. Symptoms: insomnia/hypersomnia, fatigue, poor performance, medical/psychiatric illness, drug/alcohol abuse, social impact.

Question 20

What are the three circadian rhythm disorders?

Answer 20

Delayed sleep phase syndrome
Advanced sleep phase syndrome
Shift work circadian disorder

Question 21

What are the implications of circadian rhythm disorders for sleep dentists?

Answer 21

Circadian disorders may present as sleep onset, maintenance, and offset insomnia or daytime hypersomnia
Adequate recognition and management of these disorders will facilitate success of OAT
Open communication b/w dentist, PCP, sleep specialist and patient is mandatory for proper management

Question 22

Panic disorder and sleep?

Answer 22

Common
Usually occurs during NREM sleep, transition into N3 sleep
Insomnia commonly occurs w/panic disorder
Reduced sleep efficiency and REM latency
No conclusive pattern of PSG findings

Question 23

Post-traumatic stress disorder and sleep?

Answer 23

Nightmares of traumatic event
Subjective sleep disturbance (70%-90%) – sleep study shows good sleep, but they feel that didn’t sleep well at all
No consistent abnormalities of sleep architecture

Question 24

What is the prevalence of restless leg syndrome?

Answer 24

10% of adults

Question 25

What are the correlations between age and prevalence of restless leg syndrome (RLS)?

Answer 25

Increases with age Peaks above 50 y.o. Age of onset is variable, but common onset is ≥40 y.o.

Question 26

What are gender differences in occurrence of RLS?

Answer 26

There are none. The incidence is equal between men and women.

Question 27

What is the relationship between circadian rhythm and RLS?

Answer 27

RLS is circadian linked. Discomfort/tingling/urge to move intensify in the late afternoon and worsen during sleep. Temporary relief is experienced with movement. Onset or worsening of symptoms occurs when at rest or inactive.

Question 28

What is the best treatment for RLS?

Answer 28

Sleep specialist prescribes a dopamine agonist. It works like magic for a short time. Then rebound can occur (worsening).

Question 29

What are the clinical features of periodic limb movement syndrome (PLMS)?

Answer 29

Diagnosed via PSG (EMG) Four movements in a row of .5-5 seconds that are 5-90 seconds apart Must have 5 or more per hour with arousals or 15 per hour withou arousals to be clinically significant May have arm and leg movements

Question 30

Implications of PLMD, RLS for sleep dentists?

Answer 30

Sleep onset insomnia may implicate failure of OAT PLMS can cause fragmented/non-restorative sleep Treatment of these conditions may improve daytime sleepiness and allow the OAT to be successful if OSA is a concurrent problem

Question 31

What are the clinical features of narcolepsy?

Answer 31

Excessive daytime sleepiness Disturbed nocturnal sleep Some with cataplexy (excitement, like laughter, causes temporary paralysis) Some have sleep paralysis – they wake up and can't move Hallucinations – they are dreaming but they are awake

Question 32

What is narcolepsy?

Answer 32

It is a pathological manifestation of REM: paralysis, dreaming during wakefulness (the boundaries between NREM, REM, and wakefulness become blurred). Whenever an episode occurs, the EEG shows REM sleep, even when awake! They also enter sleep going directly into REM instead of Stage 1 or else during the first 15 minutes of sleep. Called SOREM (sleep onset REM).

Question 33

What percentage of the population experiences sleep paralysis?

Answer 33

15%

Question 34

What percentage of the population has narcolepsy?

Answer 34

.04%

Question 35

What happens when narcolepsy and OSA coexist in a patient?

Answer 35

When the OSA is treated, narcolepsy becomes evident. So, if they are compliant with OSA and objective measures show success but they are still sleepy, refer out for evaluation Diagnosis and management of narcolepsy requires complete treatment of OSA Narcolepsy treatment may cause changes in sleep architecture and quality and should not be considered as failure of OAT

Question 36

What are the treatments for narcolepsy?

Answer 36

Sleepiness: modafanil or amphetamines Cataplexy: SSRIs

Question 37

Generally speaking, what are the implications of non-OSA sleep disorders in OAT?

Answer 37

Many sleep disorders may complicate the success of OAT Treatment of a primary disorder may uncover a secondary disorder Dentist's knowledge of disorders other that OSA is important as more than one disorder may be present Appropriate referral and management is mandatory for overall success of therapy