“Numerous components of wellness, and countless seams of societal fabric, are being eroded by our costly state of sleep neglect: human and financial alike. So much so that the Centers for Disease Control declared insufficient sleep as a public health epidemic. It may not be a coincidence that countries where sleep time (and quality) has declined most dramatically over the past century, such as the US, the UK, Japan and south Korea, and several in western Europe, are also those suffering the greatest increase in rates of the aforementioned physical diseases and mental disorders.”
Most adults have experienced the untoward side effects of a bad night’s sleep. Whether it is a cranky toddler refusing to go back to bed at 2am, a late night at work with an early morning meeting the next day or just one of those nights when you couldn’t force your brain to turn off, bad sleep is a wrecking ball to our productivity and to our health. We’ve all been there a time or three, waking up with a sluggish feeling the next day that just can’t be shaken even with the strongest cup of coffee.
Unlike the occasional bad night’s sleep, our sleep quality can decline slowly over time making it harder to remember how good we once felt. Some people medicate and caffeinate to cover for poor-quality sleep. The signs of declining sleep quality can be subtle and often missed in a traditional medical exam. But, dentists have a unique appraisal of the oral condition that can provide critical pieces of the quality of sleep puzzle.
Too often we oversimplify or stereotype the characteristics associated with people who sleep poorly. We look for outward signs of snoring or gasping for air while sleeping. We narrowly focus on overweight individuals with a thick neck as the poster child for sleep apnea. In my 10+ years of studying patient sleep, I never cease to be amazed at the number of slender peri- or post-menopausal women who have poor-quality sleep due to interrupted oxygen flow with no history of snoring. Sleep disturbances caused by breathing interruptions are commonly referred to as Sleep Disordered Breathing. This is a catchall phrase that includes any form of interference to normal breathing.
The Mouth Tells All
During a routine dental exam, I evaluate oral tissues and airway closely. Several red flags alert me to possible sleep pathology. Here are the more common signs of sleep disordered breathing (SDB) that I see day to day:
- Tooth grinding/clenching–this is one of the first indicators that I will observe in a patient that I suspect may have sleep disordered breathing (SDB). When sleep occurs, all of the muscles in the body start to relax. This relaxation and lack of tone can decrease the size of the airway, which can increase resistance to proper oxygen flow. Fortunately the brain is performing constant surveillance. When there is a change in breathing it can trigger a sympathetic nervous response to cause clenching or grinding of the teeth. This action brings tone to the muscles of the neck and helps to lift the tongue off of the airway to allow for better oxygen flow. The sympathetic nervous system is our fight or flight response and when it becomes overactive during sleeping hours, it severely interrupts the normal architecture of healthy sleep.
- Dry palate, inflamed tissues–saliva, the magic fluid of the oral cavity helps to moisturize and cleanse the mouth. It helps to remineralize tooth structure and aid in digestion. Saliva is also critical to help lubricate and moisturize oral tissues. When people sleep with their mouths open, the palatal tissues will become red, dry and bleed easily. During a dental exam, I will notice irritated gums that can lead to the early stage of periodontal disease known as gingivitis. I will also notice an increased amount of plaque accumulation that is a precursor to the dental disease process that causes tooth decay. Sleeping with the mouth open can completely undermine the best of oral health practices. There is no amount of brushing and/or flossing that can compensate for the damage caused by chronic mouth breathing.
- Scalloped tongue and/or tongue tie–chronic poor oral posture can lead to scalloped edges on the lateral borders of the tongue. This happens when the tongue is resting on the floor of the mouth while sleeping (or while awake) and is caused by the tongue being squeezed against the lower teeth. The tongue in this position is more likely to block the airway during sleep. When the tongue is properly placed in the roof of the mouth it encourages nasal breathing. Patients with a tongue tie will have limited range of motion with their tongues which prevents proper positioning and can lead to a compromised airway.
- Low soft palate, elongated uvula, enlarged tonsils–the anatomy of the back of the throat and airway can predispose patients to a compromised airway during sleep. I will assess during every examination as part of a regular cleaning appointment.
- Excess bone growth–known as palatal or mandibular tori can also indicate that a patient may suffer with a collapsed airway during sleep.
- Missing/extracted teeth–a common phenotype is the middle aged man or woman that was captured during a time when dentistry addressed crowded dental arches by extracting teeth. Today this is rarely practiced because we understand that the oral cavity sets the stage for proper airway development. A wide and low vaulted hard palate creates proper room for the tongue to rest and establishes the floor of the nasal sinus area. In the era of making mouths smaller, we created narrow and high vaulted palates which do not support proper tongue posture. Additionally, high vaulted palates lead to smaller nasal passageways that provide challenges to nasal breathing.
Why It Matters
One third of our life is spent sleeping. This is the time that our bodies are given to rest, repair and restore. If poor sleep habits and breathing challenges interfere with this critical time, a host of systemic conditions can result. If the body has to spend the night fighting to stay alive, then repair and restoration are inhibited and health will suffer. Sleep apnea has been implicated in systemic conditions like:
Alzheimer’s and Dementia: “A common yet underdiagnosed sleep disorder contributes to the development of dementia among adults — particularly women, a Michigan Medicine study suggests….For all adults age 50 and older, having known obstructive sleep apnea or its symptoms — as people often do not know they have the problem — was associated with a higher chance of having signs or a diagnosis of dementia in coming years.”
Cancer: “It is known already that patients with obstructive sleep apnoea have an increased risk of cancer but it has not been clear whether or not this is due to the OSA itself or to related risk factors for cancer, such as obesity, cardiometabolic disease and lifestyle factors. Our findings show that oxygen deprivation due to OSA is independently associated with cancer.”
Cardiac conditions–specifically A-fib: “Sleep apnea is highly associated with atrial fibrillation (AF), and both diseases are highly prevalent in the United States. The mechanistic underpinnings that contribute to their association remain uncertain, but numerous possible mechanisms have been proposed, including dysfunction of the cardiac autonomic nervous system (ANS). Studies have reported that apnea induces hyperactivity of the ANS, leading to increases in AF susceptibility.”
Mental Health (depression and anxiety): “In this national cohort study of 30,097 individuals, those at high risk of OSA had approximately 40% higher odds of mental health conditions at both baseline and follow-up. Over time, high risk of OSA remained associated with a 44% increased odds of reporting new mental health conditions.”
Obesity: “Sleep disruption of any kind affects the circadian system. OSA, specifically, is associated with glucose intolerance and insulin resistance. Lipid abnormalities associated with OSA include high triglycerides and low HDL. Hormones related to obesity are also altered by OSA. Ghrelin, an appetite stimulant, is higher in patients with OSA.”
Parkinson’s Disease: “Sleep problems are a common non-movement symptom for people who live with Parkinson’s disease (PD). However, a new large-scale study reveals that untreated obstructive sleep apnea (OSA) may actually increase the risk of developing Parkinson’s disease in the first place, but treating it with continuous positive airway pressure (CPAP) may help reduce that risk.
My Role
As a dentist, I am trained to look for these signs and discuss them with you. I am able to screen a patient’s sleep and work with a primary care physician or a sleep doctor to address poor sleep quality. We screen patients using an FDA approved product known as Sleep Image. We typically test 2 to 4 nights of sleep, allowing for more data to be collected and to take the stress out of thinking that one night’s sleep determines your future treatment. The screening information is collected, shared and discussed with you. We either refer patients to their primary care provider or directly to sleep providers at Dreem Health.
If you or a loved one may suffer from poor quality and/or quantity of sleep, we will discuss it together at your next dental appointment. As always, I am grateful to be entrusted with your dental care. My team and I enjoy the opportunity to get to know each of you personally. We don’t take lightly our role in optimizing your oral and physical health and we look forward to helping you in this journey.
Sincerely,
Jessica L Bishop, DDS
