“I slept like a baby…” Really, you mean you woke up crying every three hours? That is more like what happens to the spouse of someone who has OSA!
But the good news is, there are ways that adults with OSA (and their sleep partners, can get a good, restful, night’s sleep.
And, it’s not just the pharmacies and the sleep labs that can help. Did you know that your dentist actually knows a lot about OSA and sleep problems, and may have the solution you could sink your teeth into?
At my practice at Comfort Care Dentistry, I take my patients’ sleeping problems into careful consideration and treatment. Dental sleep medicine, in fact, has become popular as more and more evidence has shown a relationship between sleep problems– including sleep apnea and bruxism–, and care and treatment in the mouth. Studies and years of testing with great results for sleep solution appliances in dentistry have become a popular treatment to many pleased patients that can help both bruxism (nocturnal teeth grinding) and mild to moderate OSA. And my aim is right there with the topical, cutting edge, well tested appliances, and pleased patients–always satisfying to hear, “thank you, Dr. Phil, for a better life!”
Now you may wonder how could sleep apnea be related to your teeth?
In fact, studies have shown that Bruxism, TMJ, and orofacial pain are very commonly comorbid with OSA. Evidence has shown an association of sleep disordered breathing to bruxism.
How does that happen? The brain has a mechanism for taking care of breathing when there is the occurrence of a blocked airway that is causing an apnea. The brain knows to open up the airway and does so by getting the muscles of mastication (chewing) to start working hard and fast. That is bruxism. There is usually a grinding, clenching or gnashing of the teeth. The muscles for mastication move the jaw forward, the airway opens, and the person having an apnea takes in a deep rescuing breath, then falls back to sleep. But the airway gets blocked again and this process keeps repeating all during the night. This situation is known as sleep bruxism.
The problem situation with that occurrence is that that person wakes up in the morning with a headache and jaws and facial muscles that hurt and tooth problems. Dentists like myself will examine you and see signs and symptoms of potential bruxism with things like flattened teeth, fractured, loose or chipped teeth, worn tooth enamel, increased tooth sensitivity, tired or tight jaw muscles. Bruxism is considered a common dental problem and is reported in 1 in 3 people visiting the dentist. Research suggests that 1 in 4 people with OSA also suffer from bruxism.
In the typical scenario, this person comes to a dentist with the jaw pain, and now the dentist needs to determine what exactly is causing it, and what muscles exactly are being effected.
Mild bruxism may not require any treatment, but will require treatment if it is severe enough to cause migraine strength headaches, jaw disorders, damaged teeth, flattened fractured, loose chipped teeth, worn tooth enamel, increased tooth sensitivity, and or tired or tight jaw muscles.
Sleep bruxism is a medical disorder that is generally described as involuntary grinding and clenching of teeth during sleep. The symptoms of SB include wearing of the teeth, temporomandibular joint (TMJ) dysfunction or pain, chewing difficulties, headaches, daytime sleepiness. The determination and diagnosis of SB can be partially made based on a person’s history and dental examination, but this is not always conclusive.
Some states allow doctors or dentists to dispense a home sleep test as a preliminary screening if they suspect signs and symptoms of sleep apnea along with bruxism. But follow up with a sleep physician for final diagnosis and interpretation are the recommendations to confirm or deny a diagnosis of OSA. The whole picture is necessary to know what type of dental appliance would be helpful– is there sleep bruxism? is there OSA? — to determine what is the best solution. Your dentist will often work in close conjunction with your sleep doctor to find the best solution.
Many times, sleep studies measure the chin because of its relationship with the jaw. And the jaw has a unique function in the body. During REM sleep the brain suppresses skeletal muscle activity so you don’t act out your dreams! When the chin is measured through REM sleep, jaw activity goes down to the lowest level, and goes back up during non-REM sleep and waking. There has been a statistical significance that shows a relationship in the unusual jaw EMG activity and OSA. The jaw has a direct connection to arousal from other muscles in the body, meaning that when an arousal happens, the jaw is a participant too. That participation could be airway resistance, extra loud snoring, hypopnea, extremely slow or shallow breathing, or apnea–the stop moment of breathing. Bruxism has been shown to happen often when heart rate goes up, EEG levels change and the jaw participates in an arousal response. That is how the body best gets to wake up the person from stop breathing to get them breathing again, and/or the airway is recovered from an airway issue.
One tool that is sometimes used is Nox T3’s electromyographic EMG leads for testing muscle activity. An electrode is placed on the masseter and one on the zygomatic arch, with a ground behind the ear. The software scores and presents a Bruxism report. EMG testing is usually recommended as a next step for people with tooth wear to begin to determine a treatment plan.
The Epworth sleepiness scale and or stop bang questionnaire is also used to help identify people with tooth wear and should receive further tests by a sleep medicine consultation to determine sleep disordered breathing as well as bruxism.
The EMG electromyography monitor is usually attached to the persons cheek by analyzing the jaw muscles EMG waveforms during the night presents results that indicate number of bruxing events per hour of sleep which is called the bruxing index or BI.
Research has also shown another potential reason for the relationship between bruxism and OSA, is that both include anxiety and daily caffeine intake. Daytime sleepiness of people with sleep apnea may encourage caffeine use, which itself has been associated with a high risk of bruxism. Caffeine consumption can cause more anxiety which also can lead to bruxism. Sleep apnea can lead to depression and anxiety that leads to bruxism. So, the relationship is cyclical.
Not “oh darn it”, but “oxygen desaturation index”, which is the number of times per hour of sleep the blood oxygen level drops to 3% or more from the baseline. The drops are called the desaturations. It is measured by a device usually placed on the fingertip. When breath is disrupted in sleep, oxygen level falls. This is interpreted as an elevated ODI which puts the person at risk for an increased risk of heart attack, stroke, memory loss and other problems. A normal blood oxygen level saturation is about 96-97%. Dips to the 80-89% range is termed moderate, below 80% severe.
I like to recommend a home sleep study that measures several things: AHI, ODI, snoring index, heart rate, oxygen saturation, BEI. As a dental professional, I believe in getting the most accurate measures possible to give the complete picture necessary of your potential problems.
An AHI between 5-30 signifies that an oral sleep apnea appliance is indicated. For this, I like to consider the tap 3 elite, summoned fusion, the herbst, and the narval cc.
If the person has a BEI less than 3 than a summoned fusion will work, in my experience.
If the person’s BEI is from 3-6 then the tap 3 elite works.
If the person’s BEI is from 6 plus, I like to recommend either a herbst or a narval cc.
In my experience, I find that a narval cc can work in any scenario unless the side connectors rub the cheeks.
If the person’s AHI is above 30 than a cpap is indicated.
Other medical experts offer similar guidelines:
If BEI is greater than 2.5 then bruxism is in need of some treatment with correct appliance or botulinum toxin (Botox/Xeomin).
If BEI is s higher than 5 they advise the strongest dental material options.
If AHI is more than 5 and less than 30 a mandibular appliance for OSA is considered important therapy.
After the person takes the tests, I like to see that that the results are sent to a board-certified sleep specialist for the actual diagnosis, or they take the tests at a sleep center. With a proper diagnosis, the appropriate oral appliance can be made. Sometimes a patient retakes the sleep study to make sure the appliance is titrated correctly and sleep apnea is being cured or at least in appropriate levels of therapy.
I consider each person as an individual, with a mouth and situations unique to him or her. And, as such, there is no one appliance for everyone that will help with bruxism and or OSA–each person is unique and needs to be treated that way. It is important depending on the appliance where the mandible is positioned. Where the orofacial pain is coming from–if it is the TM joint and/or muscle trigger points. I consider these areas: Do you have sleep apnea? Do you have orofacial pain caused by muscles? Do you have orofacial pain originating in the TMJ? Do you have prior restorations? Do you have only bruxism or other conditions?
One example of technology used to measure and diagnose bruxism is the STATDDS Bruxism and Sleep Monitor. It is a home test kit worn at night. It gives a report of bruxism episodes index the BEI, and the apnea/hypopnea index-the AHI. BEI is the number of bruxism episodes per sleep hour and AHI is how many apnea hypopnea s per sleep- hour. This analyzes the data and gives a dentist a report. But if there is OSA, that is a medical condition that is usually diagnosed by a physician.
The DDME Bruxism Monitor is FSA approved for the use of diagnosing sleep disorders. It measures oxygen saturation, nasal airflow, abdominal and chest wall volume, synchrony, the presence of snoring, the magnitude and frequency of nighttime bruxism, and the parameters required for the diagnosis of OSA.
This device is a customized made upper and lower tray that fits over the teeth in order to hold the jaw forward so the tongue and throat tissues don’t collapse and cause snoring and sleep apnea. It keeps the jaw position so that it does not fall open during the night and cause a collapse of the airway, and the airway is kept clear to reduce snoring and help breathing. That feature provides room for the tongue and allows the lips to close for a comfortable fit. The TAP 3 TL positions the lower jaw forward with a range of adjustment possibilities, for the person to adjust while wearing to make sure to find a comfortable and effective position. The patient can work with the clinician for the best results in fine tuning. These devices are for the treatment of snoring and sleep apnea, and offers statistics of improving breathing and eliminating snoring in over 95% of all patients. It also is deemed effective in treating sleep apnea and reduces risks of health problems that come from sleep apnea. It is often selected for sleep apnea because it can treat the condition without the need for surgery, a mask, or medication. It is the most researched oral appliance with published studies and a market leader in oral appliances for snoring and sleep apnea, prescribed by over 7,000 dentists worldwide.
This device is from a global leader in Continuous Open Airway Therapy.
This device claims to need the least time in having to reset and readjust because it has a flexibility with calibration adjustments with interchangeable wings and fine screw adjustments at .1 mm increments. It is made with a material that is known for great comfort and fit, with wings that allow for more room in the mouth and less bulk. One patient was known to explain, “my wife said I didn’t snore, and then, most amazing thing, I started to dream and remember my dreams in the morning when I woke up!”
The SomnoDent Herbst Advance features an easily viewable calibration indicator that gives the patient and clinician better control. It has a comfortable hinge mechanism, an 8mm range of calibration for the least amount of adjustments. This appliance gives some lateral and vertical movement without disengaging it, and can be moved forward in small increments. There is also a Soft Telescope Sleep Herbst appliance. This appliance is best for snoring and mild to moderate OSA, but not bruxers or clenchers.
This device is known to be a good solution for those with mild to moderate OSA and those who do not want or cannot use a CPAP treatment. It is also the choice for snoring in the absence of OSA. It is highly customized for complex dental anatomy, it is metal free, flexible and lightweight. It repositions the tongue forward with the use of gentle suction which allows the patient to swallow in comfort. It is comfortable with a secure fit, A recent study revealed date showing a high success rate of 79% with use of this appliance for OSA–deemed an effective therapy for moderate to severe OSA.
The recent published study in the American Journal of Respiratory and Critical Care Medicine examined oral appliances compared to CPAP with the range of OSA from mild to severe OSA. And the results are: oral appliance was just as successful with eliminating health risks and with successful outcomes as CPAP.
In another study on the effectiveness of oral appliance treatment was evaluated for cognitive functions in people with OSA. The study revealed that the oral appliances not only could normalize breathing, but had a positive impact on cognitive function. The study showed improvement in vigilance and psychomotor speed. The study was done with patients with confirmed sleep apnea and apnea-hypopnea index.
Oral appliance use is now becoming a preferred choice because of new technologies, new available compliance and predictive tools, and the cost effectiveness of oral appliances versus CPAP.
There is no denying the toll that poor sleep can have on your health. As many sleep disorders begin with the mouth, your dentist is literally on the front lines of this serious public health issue.
Your dentist is in a unique position to notice the first signs of a sleep disorder, due to tooth wear indicative of bruxism, or noticing “snorers in the dental chair.” Believe it or not, many patients fall asleep during dental procedures, and this often leads us to a diagnosis of sleep disorders!
Dentists are very familiar with the mouth and the anatomy of the airway, and only a dentist can fit you properly with an oral appliance, should that be indicated.
A lot of people think a trip to the dentist can be a nightmare. But, if you are sleepy during the day, or a heavy snorer, tell your dentist during your next regular dental check-up, it may be your first step to a good night’s sleep!