Holding a Mirror to Your Patients: Using the Lamberg Questionnaire

You may think you know your patients, but if your attention is focused only on their teeth and gums, you could actually be treating ‘strangers.’ When you start learning how to treat medical problems such as sleep apnea, you take on the need and desire to know more about the whole person!
The Lamberg Questionnaire (LQ) evolved from a closing slide in my 2-day seminar titled “My Wish List”. Naturally I wanted my attendees to take action with the information that had been carefully presented, but a risk assessment tool created from the published data on the prevalence of obstructive sleep apnea (OSA) associated with comorbid medical conditions did not yet exist. Hoping someone “out there” would take on this important project accomplished nothing; so creating one myself was the natural solution. Following an invitation to do a webinar for Nierman Practice Management, I suggested this project as a topic and they completely embraced it. The work began by compiling odds ratios by medical specialty and the webinar was very successful. Subsequently, the quest was on; I continued to search the literature for all the relationships between sleep disordered breathing (SDB) and any medical conditions and my enthusiasm grew as I realized the vital importance of organizing this information. In discussing this with Steve Carstensen in Minneapolis at the AADSM meeting last June, he suggested I format the information into an article, which ultimately was published in the fall edition of Dental Sleep Practice, thereby releasing the Lamberg Questionnaire to the profession.
The reviews on the article were almost all very positive, however several commented that the questionnaire had not been validated and, without that proof of reliability, may not have a legitimate clinical application. Validation refers to scoring a questionnaire and, based on the results from a known population, the sensitivity and specificity of the instrument can then be calculated. In this case, it would mean how reliably it predicts the risk of having SDB. The process would involve administering it to a substantial number of randomly selected patients, having them tested with PSG or HSAT, and then evaluating how positive and negative predictions compared to ‘reality.’
It is true that the LQ has not been validated, but does it really matter? It is important to appreciate that assessment of risk is not a diagnosis and therefore 100% of “moderate to high” risk patients need to be evaluated with either a polysomnogram (PSG) or a home sleep apnea test (HSAT) regardless. Although some have suggested that “sleep” should be elevated to the status of a vital sign, it is not recommended to administer a PSG or an HSAT for screening purposes to otherwise healthy patients. If the patient does have medical conditions listed on the LQ it is possible that their risk of SDB is elevated and the overnight sleep test could corroborate this. An additional benefit of the LQ is that if the sleep test revealed normal sleep, the treating physician would be able to eliminate SDB as a cause of the medical condition revealed in the LQ and investigate other possible causes. The lack of validation of the LQ, although important, does not dismiss the information that may be gleaned about the causal factors of the patient’s medical conditions, even in the absence of SDB. Just asking the questions has value to the patient and practitioner.
The LQ, in my office, is also useful for internal marketing as well as patient education. It often helps initiate conversations that bring about a deeper understanding of the patient’s medical history, current status, and desires for improved health. Our hygienist is able to use it to stimulate a dialogue about sleep and educate our patients about the relationship between sleep and many common medical conditions that the patient never knew were related. Our dental hygienists are often surprised to discover that some of the patients that seemed highly unlikely candidates for having SDB, are indeed suffering with this condition.
The LQ has been requested and is used by primary care physicians to prompt similar dialogue in their offices. Several offices have asked for replacement pads of the LQ and publicly display them in their waiting rooms. The LQ is also utilized in medical specialty offices such as pulmonary, otolaryngology, cardiology, rheumatology and more. Specialists are beginning to connect the dots about the relationship of SDB and many of the conditions whose symptoms they are actively treating. In fact, several cardiology offices in our area are now more actively questioning their patients about sleep disorders.
One the most important yet unexpected benefits of the LQ is it’s value as a powerful teaching tool for my dental colleagues, as it summarizes the effects of SDB in a system-by-system approach. Any dentist involved in education can use the LQ to expose students to the enormous impact that SDB can have on the various medical systems in our bodies.
Clinicians are urged to review the patient’s answers with them and determine how the puzzle pieces fit together. If the patient checks off 1 or more items in the Section 1 (standard questions), and then checks additional items in other sections, one might sense that their risk of having SDB is elevated, and a PSG or an HSAT may be warranted. I cannot emphasize strongly enough the rewards I have felt when patients understand and appreciate that I am truly interested in them and supporting their health. Of course, that presumes that their dentist understands and is familiar with the questions being asked!
The LQ has been augmented since the DSP article was published, and the latest version is available at no charge for downloading at www.LambergSeminars.com. Alternatively, the form can be ordered in pads of 50 for less expense than printing it yourself. As more research shines light on the comorbid medical conditions of SDB, the LQ will be updated and posted at this location for your convenience.
If we, as dental professionals, are going to maximize our contributions to community health, we must go beyond excellent gum and tooth care. Use the Lamberg Questionnaire, use a different risk assessment tool, or use whatever instruments you like, but get to know your patients more fully and you will see and make a difference – to them, to your team, and to yourself as a professional.