The dentist is well positioned to screen for patients at risk for a sleep disorders, most often a sleep related breathing disorder, and when adequately trained, can treat those diagnosed with sleep apnea using an oral appliance. This treatment requires some degree of training to be able to recognize the symptoms related to the more common sleep disorders. The dentist must determine if the patient is at risk for a sleep disorder through the use of screening questionnaires, reviewing the health history, and additional questioning of the patient.
The dentist is well positioned to screen for patients at risk for a sleep disorder and, when adequately trained, can treat those diagnosed with sleep apnea using an oral appliance. This treatment requires some degree of training to be able to recognize the symptoms related to the more common sleep disorders. The dentist must determine if the patient is at risk for a sleep disorder through the use of screening questionnaires, reviewing the health history, and additional questioning of the patient.
The role of the dentist is expanding rapidly as it relates to having a role in the management of medical conditions, particularly because patients’ overall health may be impacted by their oral health. This relationship is becoming most apparent in the literature as it relates to the increased risk for cardiovascular disease in individuals with periodontal disease. A direct link has been recognized that compels practicing dentists to be more proactive in managing the periodontal disease process for dental and medical reasons.
Studies have shown that practicing dentists with some knowledge of sleep disorders are just as likely to recognize a patient who may have a sleep disorder as a physician. The average dentist along with the dental hygienist may see just as many patients on a daily basis as a family practitioner or an internist. When a physician is properly trained to evaluate for a sleep disorder or to obtain a sleep history, the possibility of uncovering one has been shown to be more likely. The same can be said for the dentist who sees patients on a regular basis.
Screening by the dentist
The first step for the dentist is to be able to screen for a sleep disorder, most often sleep apnea. This screening can be performed with the addition of very basic and simple questions to an existing health questionnaire, or the dental office can use the Epworth Sleepiness Scale (ESS). The ESS is a questionnaire commonly used in sleep medicine to evaluate a patient’s risk for daytime sleepiness and other risk factors. A more basic set of four questions, represented by the acronym STOP , can be easily added to an already existing form. Positive responses to two or more of the questions represent an increased risk for sleep apnea. Recently this has been expanded to the STOP-BANG questionnaire. These added four questions seem to be more definitive for determining risk for sleep apnea ( Table 1 ). A recent study determined that the use of these questions was able to highly predict sleep apnea. The study showed that a score of three or less had a low probability of predicting sleep apnea. However, the probability increased with a score of between three and five. If the score was greater than five, then the patient had a larger risk for having a severe sleep apnea. Essentially, if the score is zero to three, other risk factors must be considered. If the score is five or greater, the risk for severe sleep apnea increases even more. For example, if the score is eight, the probability for severe sleep apnea is nearly 82%.
|First Four Questions||Four Additional Questions|
|S: snore loudly||B: body mass index >28|
|T: feel tired during the day||A: age >50 years|
|O: observed/witnessed to have stopped breathing||N: neck size: male, ≥17 in; female, ≥16 in|
|P: high blood pressure||G: gender; are you a male|
|Yes to two or more above: at risk for sleep apnea||Add one or more from above: increased risk for moderate to severe sleep apnea|
Five basic questions may be easily added to those that dentists currently use when taking a health history, and may help identify the presence of a sleep disorder:
Do you have difficulty falling asleep or staying asleep?
Do you snore?
Are you frequently tired during the day?
Are you aware or have you been told that you stop breathing during sleep?
Is your sleep unrefreshing?
Positive responses to these questions would indicate that further evaluation is needed. At this point patients should complete the ESS and STOP-BANG questionnaires. In the presence of positive responses, patients should then be referred to their physician or a sleep medicine specialist who can further evaluate their needs.
A major concern is that the dentist may not be adequately aware or trained in sleep medicine to recognize the importance of this situation. Therefore, through asking basic questions, the possible risk may be uncovered so that the patient’s situation can be adequately addressed. Unfortunately, most dentists are not well versed in sleep medicine and related disorders. One study found that a large number of dentists were not able to recognize when a patient might be at risk for sleep apnea. However, this is slowly changing as more articles are appearing in professional journals read by dentists, continuing education courses are being presented in dental schools, and, in some cases, the predoctoral curriculum is beginning to include information about sleep and sleep disorders in some of the coursework.
Clinical Recognition of Risk for a Sleep-Related Breathing Disorder
Aside from gathering information from the health history, dentists using the ESS or STOP-BANG questionnaire must be acquainted with the clinical observations seen on a daily basis that may indicate the risk for sleep apnea. Without adequate training or awareness, the dentist may not connect these frequent findings with the risk for a sleep-related breathing disorder (sleep apnea). Recognition of these clinical findings should lead to a more detailed discussion about risk for sleep apnea, or may even lead to a more extensive examination of the oropharyngeal area in addition to the oral cavity.
The best way for those who provide oral health care, including the dental hygienist, to recognize these findings is to become familiar with the conditions that may be encountered and what these may indicate. A simplified way of correlating the clinical observations with how they may indicate a risk for sleep apnea is presented in Table 2 .
|Clinical Observation||Potential Relationship|
|Coated||At risk for gastroesophageal reflux disease or mouth-breathing habit|
|Enlarged||Increased tongue activity, possible OSA|
|Scalloping at lateral borders (crenations)||Increased risk for sleep apnea|
|Obstructs view of oropharynx (Mallampati score)||I and II lower risk for OSA
III and IV increased risk for OSA
|Teeth and periodontal structures|
|Gingival inflammation||Mouth-breather, poor oral hygiene|
|Gingival bleeding when probed||At risk for periodontal disease|
|Dry mouth (xerostomia)||Mouth-breather: may be medication-related|
|Gingival recession||May be at risk for clenching|
|Tooth wear||May have sleep bruxism|
|Abfraction (cervical abrasion/wear)||Increased parafunction/clenching|
|Long slopping soft palate||At risk for OSA|
|Enlarged/swollen/elongated uvula||At risk for OSA/snoring|
|Red patches on posterior pharyngeal wall||At risk for gastroesophageal reflux disease or allergy|
|Chapped lips or cracking at the corners of the mouth||Inability to nose-breathe|
|Poor lip seal/difficulty maintaining a lip seal||Chronic mouth breather|
|Mandibular retrognathia||Risk for OSA/snoring|
|Long face (doliocephalic)||Chronic mouth-breathing habit|
|Enlarged masseter muscle||Clenching/sleep bruxism|
|Small nostrils (nares)||Difficulty nose breathing|
|Alar rim collapse with forced inspiration||At risk for OSA/sleep-related breathing disorder|
|Posture of the head/neck|
|Forward head posture||Airway compromise and restriction|
|Loss of lordotic curve||Chronic mouth breather|
|Posterior rotation of the head||Tendency to mouth-breathe|
Other sleep disorders commonly seen in practice may be uncovered by the dentist, such as in patients who present with orofacial pain or complaints of headaches who may be at risk for insomnia. Dentists will frequently treat patients for bruxism with various types of splints or appliances. The occurrence of bruxism may indicate an increased risk for restless legs syndrome or periodic limb movement disorder. If a patient is found to be at risk for a sleep disorder, it is important for yhe dentist to know what additional questions to ask to confirm this and how to properly refer the patient for more definitive care.
The Detailed Evaluation
When the dentist is actively involved in the management of a patient with sleep apnea using an oral appliance, the need for a more detailed evaluation is essential. This evaluation would be adjunctive to the routine clinical data that may already exist if that individual is currently a patient of record. Regardless, the dentist must have some format for evaluating the patient to record data relevant to the treatment.
A more detailed evaluation is designed to assess a wide variety of factors in the oral cavity, head, neck, and airway. These areas may be of specific concern not only dentally but also as they relate to the oropharynx and nasal airway, because they may impact the proposed use of an oral appliance. This examination will not only evaluate the past history but also review the patient’s medical status, and should involve a review of the findings from the sleep study.
Medical history and chief complaints
The process of taking a patient’s medical history and chief complaints would collect information in a question-and-answer format about the patient’s symptoms and concerns. This evaluation might include questions related to common symptoms of a sleep disorder, such as poor or disturbed sleep, daytime sleepiness or feeling tired, snoring, observed apneas, tooth grinding (bruxism), headaches, acid reflux (gastroesophageal reflux disease), depression, mood swings or irritability, poor concentration, and low energy levels. This evaluation would summarize the findings from a sleep study if one was performed before this visit, and might investigate the use of continuous positive airway pressure (CPAP) along with the patient’s experience related to its use.
Review of the medical history
A review of the medical history would consider the patient’s current medical status along with any medications being taken. At this time, the possible health consequences of the sleep disorder, and more specifically sleep apnea, may become evident. Special emphasis should be directed toward headaches, cardiovascular disease, diabetes, asthma, allergy, neurocognitive difficulties, and any medications that are being used to manage these conditions. The patient’s blood pressure should also be recorded, which is common in most dental practices.
Evaluation of temporomandibular joints, temporomandibular disorders, orofacial pain
The temporomandibular joints (TMJs) should be evaluated for joint sounds, joint tenderness, or pain, and any dysfunction with mandibular movement. The range of motion of the mandible should also be recorded. Many dentists do not have an adequate background for evaluating these areas, but should become well educated and trained in this process. Any additional orofacial pain complaints other than a temporomandibular dysfunction (TMD) must also be reviewed before any treatment is initiated.
Evaluation of muscle tenderness
Muscle tenderness in the head and neck is often a component of TMD and may be related to bruxism. Travel and Simons found that muscles may have trigger points with the potential to refer pain to a distant location. In the head and neck, the activation of these trigger points may be responsible for complaints of facial pain, headache, sinus pain, TMD, and otalgia. Some of the most commonly encountered muscles and areas of referral are as follows:
Masseter muscle: this may refer to the maxillary and mandibular molars, the area around the TMJ, the ear, the temples, and the face
Sternocleidomastoid: this may refer to the forehead, the ear, the face, the top and back of the head, and over the eye. Pain in this muscle may be associated with sleep-disordered breathing because it functions as a secondary muscle in respiration and elevates the rib cage and sternum. This muscle is critical to evaluate in the presence of frontal headaches. It has the potential to refer pain across the midline and is often described as a thigh band around the head
Temporalis: this may refer to the side of the head and to the maxillary teeth
Lateral pterygoid: this is often an overlooked muscle and may refer to the face in the area of the zygomatic arch, to the TMJ, and even to the ear.
Dentists should evaluate patients for tenderness involving the muscles of the head and neck, because these may become painful if an oral appliance is used in the future. Whether palpable muscle tenderness is present is important to know in advance so that the possibility of myofascial pain associated with the use of an oral appliance may be anticipated. Measuring the mandibular range of motion first has been recommended, because palpation may aggravate the muscles, thus limiting the movement of the mandible. Often the patient has mostly muscle or myofascial pain that may refer to the TMJ or the surrounding areas, and would then be viewed as TMJ, or TMD as it is better known. Poor sleep and TMD are well-known to often coexist.
All dentists are comfortable in evaluating the dental and supporting structures of the oral cavity. This part of the evaluation is designed to assess for conditions that may impact use of the oral appliance or may be affected by it. In particular, the dentist must assess for periodontal disease and, more specifically, loose teeth. The presence of dental caries also must be evaluated. If the patient is on medication, concern about xerostomia must also be addressed. Certain oral and dental findings may be present that would limit the success of an oral appliance. These findings might include large mandibular tori, a high palatal vault associated with a narrow maxilla or posterior cross-bite, and teeth that are very short clinically, which may impact the secure retentive fit of the oral appliance.
The tongue also should be evaluated in terms of its position in the mouth at rest relative to the soft palate and the ability to view the oropharynx. This evaluation is referred to as the Mallampati score and was revised by Freidman and Tanyeri. This tool uses a scale from I to IV, with I representing a position that allows a full view of the oropharynx and IV representing a position that totally obstructs a full view of oropharynx, soft palate, and uvula ( Table 3 ). The more the tongue base obstructs the view of the oropharynx and even the soft palate, the more likely the patient is to be at risk for sleep apnea. One study showed that as the Mallampati score increases, so does the potential risk for obstructive sleep apnea and the potential for an elevation in the apnea-hypopnea index. However, the downward slope of the soft palate should also be viewed, because if the soft palate is extended further into the oropharyngeal region, the Mallampati score may be higher than reflected. A study using videofluoroscopy found that patients with sleep apnea have longer soft palates.