Why your dentist cares about your sleep quality: Downtown Dental // Nashville, TN

Our dental patients should know why we are listening (and looking) closer for the telltale signs that they may not be sleeping well.

It’s a typical day on the job: we see several patients, observe and clean their teeth and get them ready to see Dr. Clark. As we're cleaning one patient’s mouth, something seems a little off. We notice that they have a smaller mouth and a normal size tongue, and it’s difficult to see past their soft palate as they say “Ahhhh.” When we ask the patient about their week, they complain that they’ve been feeling tired and haven’t been sleeping well at night. We've experienced patients with a similar story and appearance before. What’s the connection?

Research shows that 24.1% of patients are more likely to visit their dentist than their physician for an annual exam, which places a responsibility on us to be knowledgeable about the oral signs that may be indicative of a larger health condition.

Obstructive sleep apnea (OSA) is a common disorder that affects 20-30% of adults. It is also the most common undiagnosed sleep disorder and chronic disease in Western society, with up to 80 percent of people that suffer from moderate to severe OSA unaware of their condition.

This is important considering untreated OSA can take up to 20 years off of your lifespan.  It ages your body, wreaks havoc on your immune and cardiovascular system, and dramatically decreases quality of life.

OSA sufferers often experience an inability to concentrate or focus on everyday tasks because they experience repeated microarousals, which eliminate the opportunity to have  complete restorative sleep cycles. They also can experience morning headaches, clenching and grinding, and dry mouth, which can have a severe negative impact on dental health and overall wellness.

Additionally, the disorder is linked to a number of comorbidities, including cardiovascular disease, type 2 diabetes, stroke and even Alzheimer’s. Those that suffer from OSA are two times more likely to get into a car wreck, as sleep apnea causes a decrease in cognitive functioning.

Sleep apnea can originate in the throat, which makes us the front line in detection of the physical signs that a patient may suffer from if they have OSA. Many patients with sleep apnea DO NOT experience the tell tale symptoms they have heard about;  snoring, daytime fatigue, witnessed cessations of breathing during sleep, high blood pressure, and waking from sleep with a gasp or choking sound. Instead of focusing only on these subjective symptoms, the easiest way to gauge risk of obstructive sleep apnea is to look in the mouth…

What we look for: signs and symptoms

Patients with OSA display many symptoms that can be observed simply by looking into the mouth. The MOST predictive signs include:

  • Small or recessed chin
  • Scalloped tongue
  • Eroded enamel / Clenching and Grinding
  • Mallampati Classification of III or IV

Other signs we assess that are correlated with OSA include:

  • High BMI
  • Morning Headaches
  • Narrow Arch or Small Mouth

If any of these signs are observed, or we note other symptoms that may be indicative of sleep apnea (for example, if the patient is obese or complains of a dry mouth), we often ask follow-up questions, including:

  • Do you snore?
  • Do you wake during the night for any reason?  Is it 4 hours into your sleep cycle?
  • Do you feel well rested after getting a full night of sleep?

Patients who confirm these symptoms should be further assessed. Dentists and dental hygienists can use screening tools for early detection of risk factors. If, after screening, we believe that a patient displays signs of sleep apnea, it is our responsibility to educate our patient and provide them the support they need to get tested.

OSA is not just overweight or older people who snore loudly, it's young otherwise healthy people who just have too much soft tissue (tongue, tonsils, soft palate) in the throat.  

Each Downtown Dental patient (as well as those referred to Downtown Dental by their medical doctors) are provided with a sleep consultation appointment to discuss all the risks, and benefits associated with proper treatment of OSA. Based on the medical doctor recommendation along with our own assessments, we will follow the best approach to a customized, comprehensive treatment plan with ongoing care.

[caption id="attachment_2138" align="alignleft" width="584"] The Las Vegas Institute for Advanced Dental Studies[/caption] Downtown Dental staff recently landed in Vegas for TMD Practical Advanced Training (PAT) with LVI (The Las Vegas Institute for Advanced Dental Studies), a postgraduate training center for dentists. This course was designed to teach the components of the real world TMD evaluation. Dr. Clark and his team participated in a hands on workshop to discuss TMD records, comprehensive evaluations, head and neck radiographic evaluations and the OSA/TMD relationship. We were also presented with opportunities to help solve advanced problem cases with a live patient demo in addition discussions and reviews for difficult cases brought by the participants. It was a worthwhile trip and the training made us even BETTER at diagnosing and treating head, neck, and jaw issues. [caption id="attachment_2141" align="alignleft" width="640"] DD Team Members experience the advanced TMJD course with an emphasis in posture, dental orthopedics and upper cervical health in relation the the TMJ.[/caption]
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American Dental Association Adopts Policy on Dentistry’s Role in Sleep-Disordered Breathing

In October 2017, the American Dental Association (ADA) adopted a policy on dentistry’s role in treating sleep-breathing disorders including obstructive sleep apnea (OSA). Sleep-breathing disorders are “recognized as potentially serious medical conditions caused by anatomical airway collapse and altered respiratory control mechanisms,” the ADA said in a written statement to Sleep Review. “As experts in the oral cavity, dentists are able to question patients about pertinent symptoms during routine dental evaluations, and refer patients to physicians for diagnosis. The policy was adopted to address dentistry’s growing role in the multidisciplinary care of patients with [sleep-breathing disorders].” In a news release from October, the ADA lists key takeaways that describe the role dentists should play:
  • assess patient risk for sleep-breathing disorders as part of a comprehensive medical and dental history and refer affected patients to appropriate physicians
  • evaluate the use of oral appliance therapy and provide it for mild and moderate OSA when CPAP fails
  • identify and address the side effects of oral appliance therapy
  • communicate patients’ treatment progress with referring physician and other healthcare providers.
Another point made in the policy is dentists treating sleep-related breathing disorders should stay up-to-date on the disorders and training in dental sleep medicine with continuing education. When asked what education the ADA will be providing dentists about how to screen for sleep-breathing disorders, the ADA advised that is currently under consideration. The evidence brief that inspired the policy shows there is a large portion of people could have undiagnosed sleep-breathing disorders that could potentially be identified and treated by dentists who abide by these policy guidelines. It states that the prevalence of OSA is “estimated to be 3% to 7% in men and 2% to 5% in women. Prevalence is higher (greater than 50%) in patients with cardiac or metabolic disorders, relative to the general population.” MORE: Sleep Review Magazine