For Dr. Rosa Nguyen, a dentist at Dental Depot DFW, her profession is personal, stemming from early experience volunteering as a dental assistant and a lifelong passion for helping people. With nearly 20 years of experience in the profession, she is dedicated to improving the quality of life for patients with Obstructive Sleep Apnea (OSA)—a sleep-related breathing disorder—and Temporomandibular Joint (TMJ) Disorders.

Dentists: The First Line of Defense

Dr. Rosa’s focus on OSA and TMJ began with a focus on Invisalign® treatment during her first few years on the Dental Depot DFW staff. (You can read more about Dr. Rosa’s journey to Invisalign® specialization here.) As a Diamond Plus certified provider of Invisalign®–a qualification earned by just 1% of the nation’s Invisalign® providers—Dental Depot provided Dr. Rosa plenty of opportunities to witness the second-and third-order effects of irregularities in the facial skeletal structure.

“I can recognize, with a high probability, if you snore or have sleep apnea.  Or if you are clinically susceptible to develop TMJ disorders,” says Dr. Rosa. 

Dentists earn their dental degree from an institution accredited by the American Dental Association, the nation’s leading resource for dentists.  Dentists are trained to detect the warning signs of sleep apnea, such as enlarged tonsils, a tongue with scalloped edges, worn tooth surfaces, and orthodontic concerns with an inclination for OSA. Dr. Rosa believes this knowledge, as well as their frequent interactions with patients, impart on dentists the unique responsibility of properly identifying and treating disorders like OSA.

The ADA agrees, asserting in its 2017 position statement that dentists “can and do play an essential role” in the care of patients with sleep-related breathing disorders. The ADA recommends that dentists actively evaluate their patients for possible signs of sleep apnea, both by screening for symptoms and by examining for signs of an airway that may easily be compromised.  

Moreover, while dentists cannot diagnose sleep apnea, they can help determine if a patient could benefit from a sleep test. In Texas, dentists can order a sleep test and refer patients to a sleep specialist, a physician board-certified in sleep. Dentists like Dr. Rosa, who is certified in dental sleep medicine, can also review the results of a sleep test and help to provide treatment options.

Obstructive Sleep Apnea Specialization

As a member of an elite group of 800 dentists who serve as diplomates of the American Board of Dental Sleep Medicine (ABDSM), Dr. Rosa is among the 1% of the 200,000 professionally practicing dentists in the country wholly qualified to identify and treat obstructive sleep apnea. The rigorous training and grueling admittance exam Dr. Rosa successfully completed reinforced her commitment to delivering a higher standard of care for her sleep apnea patients, but her certification was also just another example of her dedication to understanding every patient and addressing the “why” of their dental conditions. 

Obstructive sleep apnea occurs when muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax. Frequent, loud snoring, a common indicator of sleep apnea, occurs as the result of this relaxed tissue vibrating. When these muscles relax, your airway can become closed, and breathing is paused.  This pause in breathing triggers other physiological processes.  Repeated episodes of this define this sleep breathing disorder.  

Identifying the Symptoms

OSA presents several identifiable symptoms, such as excessive daytime sleepiness, frequent awakenings during the night, fatigue, insomnia, headaches, and dry mouth to name a few. This happens while sleeping, therefore OSA largely goes undiagnosed and untreated.  Obstructive Sleep Apnea affects an estimated 30 million Americans, with nearly 80% of cases going undiagnosed.  Untreated OSA and the subsequent excessive daytime sleepiness are significant causes of motor vehicle accidents.  Untreated OSA is also strongly linked to a number of other co-morbidities and long-term health complications such as hypertension, stroke, depression, cardiovascular disease, infertility, erectile dysfunction, etc. 

Treating Obstructive Sleep Apnea is near and dear to Dr. Rosa, as she discovered when two loved ones in her family developed the disorder.

When Dr. Rosa’s father was diagnosed with Parkinson’s Disease 10 years ago, she accompanied him to neurology appointments.  She began to learn more about the disease process and progression of Parkinson’s as well as its symptoms. She was particularly alarmed to learn of his REM Sleep-Related Behavior Disorder, which could accompany OSA. 

“We all heard the stories my mom would tell, so despite having a handful of physicians in our family, we all thought [his sleep disruptions] were PTSD dreams from the Vietnam War,” she says, “but they weren’t.”

During Dr. Rosa’s training, the literature confirming the relationship between OSA and Parkinson’s Disease had just been published, and Dr. Rosa requested that his doctor order a sleep test.  The doctor declined. “He said it was too late for [my dad],” Dr. Rosa says. “He said that even if my dad was diagnosed with OSA, there wasn’t much that could be done, considering the age and stage of Parkinson’s he was in.  Even if treated, his life would not be prolonged, the doctor had said.”

Dr. Rosa’s father passed away as a result of End-Stage Parkinson’s Disease, but she firmly believes that her father suffered from undiagnosed sleep apnea for the latter half of his life, which may have contributed to the onset of his Parkinson’s Disease.  

Making the Diagnosis

OSA reared its head again a few years later when Dr. Rosa’s husband was diagnosed with it—a discovery that surprised them both.

“He’s not a person you would think has sleep apnea,” says Dr. Rosa. “He’s very physically fit and didn’t even really have any symptoms aside from snoring. I’ve known him for over half of my life!  No waking up gasping or what the general population thinks of when they think of obstructive sleep apnea.”

Her husband’s sleep apnea is attributed to his skeletal anatomy.  Recent population-based studies have indicated that craniofacial structural factors account for a significant number of OSA cases in Asians.  

“We literally did not know until he had a sleep test. We thought it was just simple snoring.  The take-home here is that you just don’t know until you are tested,” she urges.  This is why a professional evaluation is crucial.

“If you broke your tooth and went to the dentist, we would take an x-ray so we could have black and white objective data to diagnose the problem,” explains Dr. Rosa. “Obstructive Sleep Apnea is no different. We need black and white objective data in order to know what happens when you sleep.”

Traditionally this would require an overnight sleep study in a hospital sleep lab, but with the advent of Home Sleep Apnea Testing (HSAT), collecting that data is now more convenient and less expensive.  “This can be done from the comfort of your own bed, in your own home.” 

Treating the Condition

Once a patient has been diagnosed with obstructive sleep apnea, several treatment options are available to aid in the right solution.  Dr. Rosa likes to use the analogy of a garden hose when describing the airway of a person with OSA and how different options treat the reduced airflow.

“Imagine you are watering your lawn with the sprinkler system and there is a kink in the hose,” she says, “and now there is no water coming out.  One option is to go to the side of the house and turn up the water pressure to force more water into the hose to hopefully bypass the kink in the hose. That is essentially what a CPAP machine does…pushing air down the trachea and working like a stent to keep the airway open.”

Sometimes surgery is the best option. “Surgery would be like going inside the house to grab a kitchen knife to simply cut the hose. Water would definitely be coming out then.”

Another option is to simply unkink the hose. FDA-approved oral appliances—like those provided by Dr. Rosa—“unkink the hose” and open up the airway by shifting the lower jaw forward and holding it in place, preventing the tongue from relaxing into the throat during sleep. 

Dr. Rosa likens the treatment process to starting a patient on blood pressure medication, where the patient is started on a lower dose, then monitored to check its efficacy, with the physician prescribing dosing adjustments as needed.

“We’ll fabricate the customized oral appliance for you, then calibrate it by adjusting the mouthpiece to make sure it’s working properly.” Dr. Rosa provides subjective evaluations regarding any lingering symptoms and follow-up sleep testing to evaluate how well the appliance is working.

“I like to see the proof in the pudding,” says Dr. Rosa. “I want to make sure the patient’s disease condition is being appropriately managed for the best quality of life.”

Connecting the Dots: OSA and TMJ

It was this dogged approach to the details of sleep apnea treatment that drew Dr. Rosa’s attention to one of the executives at Dental Depot DFW.

“[This executive] wears an oral appliance for sleep apnea.  He loves it!  He said he cannot sleep without it.  At his cleaning appointment, he indicated his oral appliance helped to control his nighttime bruxism, but what could be done for his daytime clenching and grinding?”

She was unsurprised—Dr. Rosa has worked alongside him for the better half of a decade.  “His level of daytime stress is through the roof!  He cannot sit still…he is constantly moving and fidgeting,” Dr. Rosa explains, “and I noticed that his jaws were constantly clenching and grinding throughout the day.  By nature, he is a tense person.  This was years before we diagnosed his OSA.”

“Many patients with sleep apnea complain of clenching and grinding during our initial consultation appointment.  Oftentimes this is the eliciting factor why they seek treatment with me.”   

Was TMJ present before the OSA?  Did the undiagnosed and untreated TMJ cause OSA?  “In my experience, they seem to go hand in hand.”  Her diplomatic training also confirmed this.  

So, the search was on for better treatment options for TMJ.  

Jeff Hester is owner of Hester Designs. You may recognize some of Jeff’s work for clients like Tinker Federal Credit Union, Myriad Gardens, Canterbury Chorus Society, Ronald McDonald House OKC, and many others. Jeff considers himself an organizer of visual communication and systems. Jeff uses art, design, programming, and observation to create clear communications and tell interesting stories. Over the last two years Jeff has taken a deep dive into Accessibility and design and usability techniques to help make his designs more inclusive to all people.

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