Sleep Apnea: a NOT-so-Silent Killer

by Kathleen Bokrossy, RDH President of rdhu

What dental hygienists need to know to help save lives

Obstructive sleep apnea (OSA) is a disorder characterized by upper airway collapse during sleep. OSA is one of the most prevalent sleep disorders and is potentially fatal, affecting approximately 4-9% of the adult population.1 Like most sleep disorders, OSA is unrecognized, underdiagnosed and undertreated with an estimated 70-90% of cases going undiagnosed.1 Dental Hygienists are the first line of defence in recognizing and screening for potential OSA. We play a critical role in improving the quality and longevity of life of our clients.

Understanding the sleep disorder, how it affects our clients, how to screen for potential OSA, and recognize when to refer is in our area of influence.

My interest in sleep apnea began because of my own personal journey.

Here I am, in the dental profession, president of a professional development company and unbeknownst to me, I suffered from sleep apnea for far too long. Not only sleep apnea, but severe sleep apnea. I was one of the undiagnosed statistics.

It was because of this diagnosis that I decided to dig deeper into this topic and have made it a passion to bring awareness to this disorder.

I had seen many different dental hygienists (as a client) over the years, a cardiologist, my GP and even a couple of different dentists, and not one of these healthcare providers ever asked me about my sleep. Seems so simple to ask, but it never came up during any assessment or medical history questionnaire given.

I have been happily married for a long time and my husband, not once, ever mentioned (God bless him) that he noticed something peculiar while I slept. For instance, loud snoring, choking and gasping for air, grinding and bruxism, to name a few.

It wasn’t until I was away and sharing a room with my friend, Jennifer Turner (who I was co-presenting with the next day) that she admitted “Kath, I used to hear you gently sleep and it made me happy to know that you were getting sleep, but now, I feel like I am sharing a room with a truck driver.” (No offense to truck drivers! But you can understand what she was implying!) I had a physical booked the next week with my GP and during this appointment I mentioned to her that my friend mentioned my snoring. “You snore?” she asked. “I am going to book you in with the sleep clinic.”

Looking back at how long I was suffering was truly disheartening. I thought perhaps I suffered from anxiety, because I couldn’t sleep at night. One night in particular stood out for me. I was away in the States for RDH Under One Roof, where I was a part of the mega session and presenting to 2200 people the next morning. I met with my friend and co-presenter Jo-Anne Jones, we had a light dinner and off to bed we went (this time we had separate rooms). After 1.5 hours of sleep I was up for the day. I took a selfie and sent it to my husband. I was so upset. How was I going to get up there on the stage that morning and present to a large audience? I felt terrible. I was in a fog and couldn’t think straight. Luckily, I rallied. Ordered a Coca Cola (which was my secret weapon prior to presentations at the time – that I don’t need now, thanks to my CPAP!), did my hair and makeup, and was ready for the day.

No matter how a client looks, you never know what that client is going through or what their concerns are. We can’t prejudge or assume something by their outward appearance alone. Questions need to be asked. We need to start the conversation.

For many years I suffered from:

  • Brain fog
  • Memory issues
  • Weight gain
  • High cholesterol
  • Day-time sleepiness
  • TMJ problems
  • Bruxism
  • Limited opening (due to my TMJ problems)
  • Nightmares
  • Snoring
  • Gasping for air/choking
  • Acid reflux
  • Tinnitus
  • Frequent trips to the washroom at night

All of these symptoms are related to sleep apnea.

I waited 6 months to get into the sleep clinic for my initial assessment. In the meantime, I went for a “new patient exam” with my friend Dr. Samson Lee. During the assessment he stated ‘Class 3 Tongue’ to his assistant. “Class 3 Tongue?”, I asked. I had not heard that term since dental hygiene school, to be honest.

He refreshed my knowledge on Mallampati Classification. (Figure 1)

Figure 1: Mallampati Classification
Source: Wikipedia. User: Jmarchn

A simple physical trait that can be indicative of OSA is the client’s Mallampati Classification. Clients with a Class 3 or Class 4 Mallampati Classification are most likely to have some degree of OSA due to the small space in the throat for the passage of air.2

Once the results for my test came in, the sleep clinic had me in for my fitting of the CPAP machine that night. There was no waiting as my results indicated that I had severe sleep apnea.

So, what is sleep apnea?

Sleep apnea is characterized by repetitive apneas during sleep. An apnea is the complete interruption of breath for at least 10 seconds.2

Characterized by partial or complete narrowing of the pharyngeal airway during sleep.

It is defined as a condition in which there is a decrease of oxygen intake (hypopnea) or temporary cessation of breathing (apnea). 2

This chronic, multifactorial, and potentially life-threatening disorder is associated with a reduction in oxygen levels, increased carbon dioxide in the bloodstream, and numerous medical conditions.3

Results in:

  • Disruption in sleep cycle
  • Daytime fatigue
  • Deprivation of deep and REM sleep
  • Interferes with important physiological processes

Obstructive sleep apnea increases the risk of morbidity and mortality. With a diagnosis and appropriate treatment, coexisting health conditions can improve.

This is why I became passionate about this topic and want to share with dental hygienists to help empower you to realize that you can really make a difference in someone’s life with one simple screening tool.

We are at the first line of defense.

There are many dental practices who specialize in sleep and have fully implemented assessing and treating or referring to the appropriate specialist to help clients and patients; however, there are still a number of professionals who don’t screen for this disorder.

According to the Institute of Medicine (US) Committee on Sleep Medicine and Research; obstructive sleep apnea is an unmet public health problem. 4

During my initial research I came across a study that was conducted on a group of dental hygienists. The purpose of this study was to determine the knowledge and attitudes of OSA among this group. The conclusion stated that dental hygienists perceive that assessing patients for OSA is important, however they have moderate knowledge of the disease. Results support incorporating OSA into dental hygiene practice through additions to the dental hygiene education curriculum and ongoing professional development courses with the goal of improving the screening and referral of patients presenting with OSA symptoms.1

Sleep apnea can lead to many diseases and conditions; such as, obesity, diabetes, cardiovascular disease, increased cholesterol levels, it can affect the brain function, mood and behavior, just to name a few.

My suggestion, establish an obstructive sleep apnea assessment protocol for your practice:

  1. Get the team on board. Educate the entire team on this disorder. Dr. Viviano, from Mississauga, Ontario has an educational facility where dental teams come from all over the world to participate in Sleep CE classes ( There are also online courses available through this website and
  2. Determine which assessment tool you are going to implement. There are many available online:; Epworth Sleepiness Scale
  3. Establish options for treatment. (oral appliance or CPAP)
  4. Who will you collaborate with? Sleep specialist? Refer first to the GP.
  5. Implement a follow-up protocol. Now that your client/patient is aware that they have this disorder, be sure to check that they are wearing their appliance or CPAP every night. Clients need encouragement and reinforcement. We need to make sure that the client understands the severity of their condition so that they work through the initial stages of adapting to their new device at night. Work with them to see what treatment option works best for them.

Obstructive sleep apnea is a huge topic and one that you can do a lot of research on.

My goal in writing this article was to bring awareness that assessing for obstructive sleep apnea, even by adding a few questions to your medical history and update, is essential. You could follow some of the screening tools or simply implement questions like: Do you snore? Do you wake up choking and gasping for air? Are you tired and feel like you are in a fog?

I recorded a 1-hour CE online course on sleep apnea (Sleep apnea…a NOT so silent killer: What dental hygienists need to know to help save lives); which includes many references and extra resources. If you are interested, please go to and you will receive instant access to this online presentation.

You can help someone by not only extending their life but also by giving back their quality of life. I know I have been feeling great since starting my treatment!


  1. Obstructive Sleep Apnea Knowledge: Attitudes and screening practices of Minnesota dental hygienists; Author: Reibel YG; Pusalavidyasagar S; Flynn PM J Dent Hyg. 2019 Jun;93(3):29-36.
  2. Obstructive sleep apnea
  3. Dimensions of Dental Hygiene: Screening for Sleep Apnea
  4. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine (US) Committee on Sleep Medicine and Research Harvey R Colten, Bruce M Altevogt. Extent and Health Consequences of Chronic Sleep Loss and Sleep Disorders;

About the Author

Kathleen is the president of rdhu, a Professional Development company, which provides team events, hands- on programs and online learning to help Transform the Dental Hygiene Experience for the clinician, the client/patient and the practice.

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