Dental Sleep Medicine Is Already Inside Dentistry
Virtually every dental issue may be associated with airway problems
Steven Lamberg, DDS
Patients' dental and medical histories provide a treasure trove of information that can reveal airway problems and impact your treatment goals and sequence. In fact, every time you pick up a handpiece, there could be evidence of an airway problem. Please hold those angry emojis and suspend your disbelief while I share the evidence that connects the dots.
Restorative dentistry addresses problems such as abnormal attrition, erosion, abrasion, abfractions, chipping, cracking, decalcification, caries, and tooth color and shape issues—just to name a few. These can all arise from biomechanical and functional problems born from airway dysfunction. When the nasal passages are obstructed, two things happen. First, the mouth opens, which leads to a dry oral environment and decreases the saliva's capacity to buffer the acids produced by bacteria. And second, the resulting lowered tongue posture itself compromises the airway while failing to provide a scaffold for the arch form. Open mouth posture can lead to the decalcification of enamel, tooth color changes, and even worse, the development of caries.
Excessive wear and broken restorations from clenching and or bruxism can be the result of an unregulated sympathetic nervous system. Although there could be multiple issues that jack up the sympathetic nerves, the airway is the most common smoking gun. In addition, deleterious jaw relationships can develop, which create signature wear patterns. Before any reconstruction, a sleep study is always indicated. Simply restoring an arch and making a night guard without a sleep study may allow the continuance of sympathetic activity, which is detrimental to all of the body's systems, and it may even make it worse by displacing the tongue base further into the airway.
Endodontic concerns result from decay or cracks from occlusal trauma, both of which can be a result of mouth breathing and increased sympathetic activity, and periodontal problems can also be related to airway problems. A recent study from 2022 revealed that the highest prevalence of stage 3 periodontitis was among patients with severe obstructive sleep apnea (OSA).1 The study concluded that "periodontopathogenic bacteria of the orange complex, such as Prevotella melaninogenica, and the yeast Candida albican saltered the oral microbiota of patients with periodontitis and OSA in terms of diversity, possibly increasing the severity of periodontal disease." In addition, a 2022 systematic review that included 43,414 individuals showed that OSA patients had a significantly increased risk of periodontitis.2
Prosthodontics, implants, and oral surgery can be considered as a group representing tooth loss, and tooth loss has been associated with the risk of OSA. One study with 7,305 participants found that the prevalence of a high risk for OSA increased 2% for each lost tooth.3 Furthermore, the study demonstrated that even relatively minor levels of tooth loss (ie, 5 to 8 lost teeth) were associated with a 25% greater prevalence of being high risk for OSA. The researchers concluded that tooth loss may be an independent risk factor for OSA.
With the advent of aligner therapy, orthodontics has exploded in general dental practice, but what is behind this epidemic of crowded and crooked teeth and why is there so much relapse? We now know that mouth breathing influences facial form and is a predisposing factor to the development of "long face syndrome." This is correlated with very narrow arches, a lowered position of the hyoid bone, and an anterior-inferior postured tongue with significant downward inclination of the mandible—all of which challenge the integrity of the airway. Fortunately, the vast majority of these patients can be easily diagnosed early in life and avoid adult breathing problems.
Now that you understand how many dental issues can be indicative of the presence of airway issues, I hope this serves as a clarion call to expand your vision from simply treating the teeth to treating the entire patient by integrating dental sleep medicine. I've found it to be incredibly rewarding. Think you can't do it? Nelson Mandela once said, "It always seems impossible until it's done." But I've done it, so it's not impossible for you either.
About the Author
Steven Lamberg, DDS, is a diplomate of the American Board of Dental Sleep Medicine and a scientific advisor at the Kois Center. He maintains a private practice in Northport, New York.
References
1. Tellez-Corral MA, Herrera-Daza E, Cuervo-Jimenez HK, et al. Patients with obstructive sleep apnea can favor the predisposing factors of periodontitis by the presence of P. melaninogenica and C. albicans, increasing the severity of the periodontal disease. Front Cell Infect Microbiol. 2022;12:934298.
2. Zhang Z, Ge S, Zhai G, et al. Incidence and risk of periodontitis in obstructive sleep apnea: A meta-analysis. PLoS One. 2022;17(7):e0271738.
3. Sanders A, Akinkugbe A, Slade G, and Essick G. Tooth loss and obstructive sleep apnea signs and symptoms in the US population. Sleep Breath. 2016;20(3):1095-1102.
