What is Dental Sleep Medicine?

A 58-year old lady with a long history of stopping breathing during snoring while asleep, high blood pressure and constant tiredness attends her doctor regularly without receiving treatment, has a stroke. Who was responsible?

History

Prompted by her husband who found her snoring to be both disruptive and worsening, Mrs. E. attended her doctor of six years, Dr. M.

Upon hearing her story, he took her blood pressure, (for the first time in six years) and told her that it was higher than normal and that she should see the pharmacist next door for some advice sheets including weight loss.

She attended and the pharmacist took her blood pressure and informed her that it was high at 180/155. (High) He said that normally it would be around 130/90 at her age. The pharmacist gave her an advice sheet that advised her to limit salt, eat a balanced diet, exercise, stop smoking, and lose weight. He suggested it be checked again in a week.

Later she asked again about her snoring again and that her husband said she occasionally stopped breathing. Dr. M. said that it was likely that she had some nasal congestion and could prescribe nasal spray, but that her high blood pressure needed to be treated (he wrote a prescription for an ACE inhibitor hypertension drug).

Mrs. E. continued to see her pharmacist and her blood pressure slowly reduced. Three months after her initial consultation with her doctor, Mrs. E experienced ischemic stroke.(A stroke due to a clot and brain tissue damage as a result of this lack of oxygen.)

Investigation

Upon diagnostic imaging at the hospital to which she was admitted, it was noted that she had suffered several ‘silent strokes’ previously, of which she was unaware.

Her attending neurologist seemed interested in her story of gasping during her chronic and loud snoring, her husband’s claims that she would occasionally  “stop breathing for 20-30 seconds at a time” and her high blood pressure.

Following his requested sleep test, a diagnosis ‘moderate level’ obstructive sleep apnea (OSA) with loud snoring was made. Asked if Dr. M. should have known this, Mr. E was told “possibly”.

Mrs. E. was contacted by a CPAP company who told her that the Dr. M. had asked them to provide CPAP. As her husband’s friend was a dentist, she asked if they could provide a dental appliance for her but was told that they didn’t work as well as CPAP and offered her a CPAP trial instead.  After two weeks of trying it unsuccessfully, she found it impossible to wear all night gave up on treatment and decided to continue without treatment.

Six months later she experienced a debilitating stroke which left her unable to walk or talk.

Review

Mr. E. discovered that his wife had treatment options that he was not offered and contacted a lawyer who discussed the scenario with an expert witness. While the facts of the matter appear clear, there are many issues that must be addressed in a report and expert opinion to ensure that accurate facts are presented robustly.

An apparent lack of knowledge and insight prevented the physician from providing impartial advice whereupon a severe and debilitating stroke may have been avoided. The same can be said of the CPAP provider; alas the industry has no regulation. Following a report well evidenced with current Canadian studies and guidelines, the case was settled ‘out of court’, to avoid ‘unnecessary court time and cost’.

Question

How many times are we left ignorant of possible alternatives? The true meaning of consent is to be provided with options to the treatment recommended, if they exist. In this case they did, the patient and her husband were not told the truth and the results very unfortunate.

If the doctor had recognized the potential dangers of snoring and obstructive sleep apnea would her stroke have been avoided? Is the doctor negligent in only offering one option when in fact several exist? In BC the CPAP providers are not regulated and as salespeople can chose to share information or not depending on their bias.

In a disease that affects up to 20% of the adult population and has been shown to be associated with high blood pressure, heart attack, stroke and diabetes – why do many physicians frequently not even enquire of the relevant questions to their patients and when they do, why do they often only offer one option (that may not be accepted to the patient?) This is failure of consent.

The lady in question died shortly thereafter although he had planned to have his case reviewed by a dentist providing such care. Alas he was too late. Would things have been different if she’d been treated with a fair, honest and unbiased consenting process? The insurance company were not prepared to risk the chance that they would – this doesn’t help the lady, however.

Author – Stephen Bray DDS

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