DENTAL BLOG

A Closer Look at the Visible Signs of Sleep Apnea

Sleep health has an incredible impact on long-term patient wellness, and dental health is no different1. In honor of National Sleep Awareness Week, March 14-20, dentists should take time to understand what patients’ teeth can reveal about their sleep quality and their overall health. 

This visual guide outlines the visible signs and common symptoms associated with obstructive sleep apnea (OSA). The American Dental Association (ADA) has identified several indicators that patients likely suffer from obstructive sleep apnea2, including:

  • Bruxism
  • Large or scalloped tongue
  • Retrognathia
  • Narrow/obstructed airway

Those suffering from OSA have a higher risk of experiencing heart disease, obesity, and diabetes, among other chronic illnesses2. As OSA is often underdiagnosed, dentists who remain educated on how to identify these visible signs will be able to advocate for and help these patients.

Learn These Four Visible Signs of Sleep Apnea

The characteristics that present the most dramatic visible indicators, their associated.

In recent years, the American Academy of Dental Sleep Medicine (AADSM) has advocated for standardization of diagnostics and treatment in dental sleep medicine3. A large part of that effort focuses on developing consistent dental education materials that show how sleep disorders like OSA may present in patients. 

Practicing dentists should seek continuing education to recognize and manage their patients’ sleep disorders effectively. For OSA specifically, the characteristics that present the most dramatic visible indicators, their associated symptoms, and their typical presentations are as follows.

The characteristics that present the most dramatic visible indicators, their associated.

symptoms, and their typical presentations are as follows.

Bruxism

Bruxism

Bruxism, or teeth grinding, presents as excessive dental attrition, particularly along the incisal and occlusal surfaces of teeth.3 Unlike normal attrition, which occurs from day-to-day wear and tear, bruxism significantly damages dental crowns and exposes the fragile dentin beneath.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape3, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Bruxism, or teeth grinding, presents as excessive dental attrition, particularly along the incisal and occlusal surfaces of teeth.4 Unlike normal attrition, which occurs from day-to-day wear and tear, bruxism significantly damages dental crowns and exposes the fragile dentin beneath.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape4, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Over time, the mandible and maxilla bones, and therefore the upper and lower gums, come closer together as the enamel and dentin wear away and teeth take on a flattened shape3, as shown in this image (data on file). This contributes to the oral obstruction responsible for OSA symptoms.

Large or Scalloped Tongue

Large or Scalloped Tongue

Patients with OSA often present with a scalloped tongue5, as pictured here (data on file). A scalloped tongue will appear swollen or puffy. Often, patients unconsciously push their tongues into their mandibular teeth as they strain to breathe while asleep. This leaves visible waves or notches that form uneven ridges on the perimeter of the tongue surface.

Retrognathia

Retrognathia

As the illustration shows (data on file), retrognathia is a specific type of malocclusion in which the maxillary teeth overhang mandibular teeth. This is also known as overclosure6, a form of teeth misalignment that is especially common among patients with bruxism. Retrognathia can worsen the vertical collapse seen in bruxism sufferers, which further constricts patient airways as seen in OSA.7

Narrow or Obstructed Airway

Narrow or Obstructed Airway

The American Dental Association describes this visible sign of OSA as “increased volume of lateral pharyngeal walls, tongue and total soft tissue.”2 As shown in these illustrations and images (data on file), obstructed airways can leave very little room for sufferers to intake full breaths of air, which is why OSA can interrupt patients’ sleep hundreds of times in a single night1.

Conclusion

These four physical characteristics are among the most dramatic visible indicators of obstructive sleep apnea found in the oral cavity.2 When dentists learn to identify these indicators and the symptoms that accompany them, patients with undiagnosed OSA are more likely to receive effective care that improves their oral health, as well as their longevity and quality of life.1

In addition to continuing education, the AADSM recommends that dentists who treat patients with OSA acquire some form of accreditation in sleep medicine3. This can include certification from a non-profit working in dental sleep medicine or an official designation based on clinical experience in the field. Doing so ensures that dentists are providing OSA patient with consistent, high-quality care that adheres to professional and ethical standards.

References:

  1. American Academy of Dental Sleep Medicine. Obstructive Sleep Apnea. https://www.aadsm.org/obstructive_sleep_apnea.php. Accessed March 17, 2021.
  2. American Dental Association. Oral Health Topics – Sleep Apnea (Obstructive). https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive. Accessed March 17, 2021.
  3. Levine M. Bennet K.M. Cantwell M.K. Postol K. Schwartz D.B. Dental sleep medicine standards for screening, treating, and managing adults with sleep-related breathing disorders. Journal of Dental Sleep Medicine. http://dx.doi.org/10.15331/jdsm.7030. Accessed March 24, 2021.
  4. James L. Clinical signs of bruxism. Dentalcare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/ce485/clinical-signs-of-bruxism. Accessed March 17, 2021. 
  5. Holland K. What causes a scalloped tongue? Updated March 7, 2019. Healthline. https://www.healthline.com/health/scalloped-tongue
  6. James L. Occlusion. Dentalcare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/ce485/occlusion. Accessed March 17, 2021. 
  7. Jenzer AC. Retrognathia. StatPearls [Internet]. Published July 7, 2020. https://www.ncbi.nlm.nih.gov/books/NBK538303/.. Accessed March 17, 2021.
Dental screening

Experts assert to effectively treat patients, dentists should be aware of chronic conditions that impact overall health. Often, this requires dentists to be prepared to diagnose these conditions themselves.1 In particular, obstructive sleep apnea (OSA) represents a nexus of underdiagnosed disease that compromises overall health and directly relates to dental care.2 As such, dentists could incorporate diagnostic tools like home sleep apnea tests (HSATs) into their practice to improve how patients with this condition can access and experience treatment. And because sleep apnea is a key risk factor for cardiovascular disease and other chronic conditions, OSA screening is a great way for dentists to elevate their role in patients’ overall healthcare.2

How Dentists Can Play a Key Role in Patients’ Overall Health

Due to their knowledge of oral cavity and craniofacial structures, studies say dentists occupy a uniquely qualified position to screen patients for anatomical signs and physiological symptoms of OSA.1,2 Using a combination of clinical examinations and home sleep apnea tests, dentists could potentially recognize the visible signs of undiagnosed OSA as described by the American Dental Association that other health professionals may not have the opportunity to uncover.

Dentists’ involvement in OSA treatment has been shown to deliver improved long-term outcomes and patient satisfaction when compared to medical care alone, through patient education, regular oral examinations, and oral fittings for oral appliances that treat sleep apnea.2,4,5

The Link Between Sleep Apnea and Dental Care

Despite OSA’s disruptive nature, patients may only perceive their symptoms as simple restless sleep, snoring, or daytime drowsiness without a specific cause2. Obstructive sleep apnea is particularly relevant to dental care because of its inherent involvement in oral health and anatomy. Many of the signs and symptoms that potentially indicate an OSA case can be observed while conducting a patient history or a bi-annual oral exam during dental care, including2:

  • Bruxism
  • Scalloped tongue
  • Retrognathia
  • Large tonsils
  • Retrusive jaw
  • Large neck circumference

After taking a clinical exam and administering relevant questionnaires, dentists can provide patients with home sleep tests to put them on a path to confirm a diagnosis of obstructive sleep apnea and show patients whether they are experiencing more than a simple poor night’s rest.2 Home sleep tests like the WatchPAT® One device serve to help a dentist incorporate this additional business stream into their practice very easily, for the dentists themselves, additional staff, and their patients, for whom lab sleep studies may seem a burden.

Dentists Can Act as a Supplement to Medical Care

Left untreated, obstructive sleep apnea poses danger to both patients’ quality and quantity of life. Studies clearly show systemic illnesses like cardiovascular disease and hypertension directly impact oral health, and vice versa, so dentists could consider equipping their practices with appropriate tools to identify dangerous conditions like OSA. Home sleep apnea tests are a useful diagnostic tool that are a cost-effective way to assess potential OSA in patients exhibiting typical symptoms. 

By adopting effective, convenient tools for OSA screenings into their practice, such as a home sleep tests, dentists can refer and treat previously undiagnosed patients early and accurately. This allows patients to receive sleep apnea care that integrates dental expertise when needed.4 Gathering information through clinical exams, sleep apnea devices, and patient questionnaires, dentists are able to fill the role of “oral physicians,” to the benefit of the health of the patient and the community.3

Dental OSA Screenings Improve Long-term Outcomes and Patient Satisfaction

When operating in the role of “oral physician,” dentists have two distinct advantages regarding primary healthcare screenings:

  • Dentists likely see patients more often, as patients are used to making and keeping dental appointments twice a year.1
  • Patients with diagnosed OSA largely prefer oral appliance therapy (which dentists can custom fit for patients) over traditional CPAP therapy.5

Dentists who screen patients for OSA with home sleep apnea tests will be involved in treatment of the condition from the start. Working in conjunction with patients’ medical care teams, dentists can be called upon to provide properly fitted sleep apnea devices that patients prefer over positive airway pressure (PAP) machines.

CPAP Therapy vs. Custom-Fit Oral Appliances

As many as 50% of patients prescribed CPAP therapy either fail to fulfill their prescription or stop treatment before indicating, primarily because of mask discomfort.4 In addition to mask discomfort, OSA patients may also experience oral dryness and nasal congestion. 

These side effects contribute to poor patient adherence and satisfaction with OSA treatment, which is why dentists can make a significant difference in patients’ long-term health. Without consistent treatment, patients with OSA will struggle with chronic exhaustion, poor attentiveness, lowered productivity, and anxiety.4

In contrast, oral appliance therapy often results in greater treatment adherence and success among patients with mild to moderate OSA. For those who struggle with the discomfort of CPAP therapy, their dentists can custom-fit oral appliances that are much easier to sleep with comfortably.2,5

Conclusion

As a result of their specialized expertise, dentists provide a convenient and logical avenue to identify obstructive sleep apnea in patients.1 Unlike other healthcare professionals, dentists are more likely to see patients for frequent follow-up visits, which makes them an accessible source for primary care screenings patients may not otherwise receive.3

In addition to the above advantages that dentists have in being the one to make a difference in a OSA patient’s life, WatchPAT® One, the only fully disposable home sleep apnea test, can integrate into dental practices seamlessly with little to no investment. By monitoring OSA patients and remaining involved in their care, dentists can elevate their role in collaborative healthcare that puts patient health first.

References:

  1. Lavanya R, Gandhi Babu DB, Chavva S, Boringi M, Waghray S, Yeladandi M. The role of oral physicians in predicting the risk of obstructive sleep apnea: A case-control study. Imaging Sci Dent. 2016 Sep;46(3):167-171. https://doi.org/10.5624/isd.2016.46.3.167 
  2. Oral health topic – Sleep apnea (obstructive). American Dental Association. https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive
  3. Gambhir RS. Primary care in dentistry – an untapped potential. J Family Med Prim Care. 2015;4(1):13-18. https://doi.org/10.4103/2249-4863.152239 
  4. Knight V. I’m a CPAP Dropout: Why Many Lose Sleep Over Apnea Treatment. Khn.org. https://khn.org/news/im-a-cpap-dropout-why-many-lose-sleep-over-apnea-treatment/. Published July 17, 2019. Accessed February 2, 2021.
  5. Callender E. Treatments for Obstructive Sleep Apnea. Sleepfoundation.org. https://www.sleepfoundation.org/sleep-apnea/obstructive-sleep-apnea/treatments. Updated September 4, 2020. Accessed February 2, 2021.
Dentist

Dental medicine should always be a part of comprehensive care that puts patient health first according to the American Academy of Sleep Medicine (AASM)4 and the American Academy of Dental Sleep Medicine (AADSM).5 Based on American Dental Association (ADA) recommendations, dentists like you are “ideally positioned to identify oral or craniofacial abnormalities” that impact patients’ overall healthcare1.

These organizations assert that when evaluating new patients, dentists should screen for (and potentially treat) obstructive sleep apnea (OSA), a dangerous sleep disorder affecting many Americans’ overall physical and dental health today1. Just as oral cancer screening has become standard in dental care, the ADA has advocated for OSA screening to become part of dental practice.

Doing so will allow you to provide appropriate, collaborative dental care that supplements ongoing medical treatment and improves long-term health outcomes in your practice.

Obstructive Sleep Apnea Prevalence and Risks

In the US, obstructive sleep apnea represents over 80% of sleep-related breathing disorders2, affecting as many as 54 million American adults today1.

According to the AADSM, sleep dentistry is among the fastest growing specialties in dental medicine1. Providing OSA screening as part of dental practice means you may be helping to provide much needed care for this growing patient population.

In addition to leading to a variety of dental problems, OSA is correlated with several life-threatening comorbid conditions that can impact your patients medical and dental care3, including:

  • Cardiovascular disease
  • Type II diabetes
  • Hypertension
  • Stroke
  • End-stage renal disease

Beyond these chronic conditions, OSA is correlated with a variety of dental and oral health issues4, such as:

  • Bruxism
  • Enlarged or scalloped tongue
  • Periodontal disease
  • Battered uvula

Identifying whether your patients meet criteria for an OSA diagnosis may allow you to offer collaborative care with their medical providers and provide insight into other dental issues they may have down the line.

OSA-related Risk Factors and Symptoms

Dentists looking to incorporate OSA screening into their care should learn signs of OSA as well the condition’s related risk factors. OSA screening may be indicated for patients exhibiting the following features or symptoms2

  • Large tongue or tonsils
  • Large neck circumference
  • Nocturnal choking or gasping
  • Obesity
  • Loud snoring
  • Interrupted breathing during sleep
  • Daytime sleepiness or exhaustion

As OSA is a common and dangerous sleep disorder when left untreated, providing OSA screenings may improve the quality of dental care your patients receive. 

Importance of OSA Screening in Dental Care

Patients may communicate or show some of the above features during standard patient history intake. However, OSA sufferers are often unaware of OSA-related symptoms that are interrupting their sleep and causing them to feel poorly rested over time3

When patients are unaware that they are sleeping poorly due to interrupted breathing while sleep, they are unlikely to seek care, which explains why OSA is underdiagnosed. Screenings that you provide in your dental practice may help undiagnosed OSA sufferers identify an overlooked and dangerous threat to their health.

Using at-home diagnostics like the WatchPAT® ONE or WatchPAT® 300 can make these screenings accessible and cost effective, not only for you and your practice, but for your patients as well. In addition to the above benefit, choosing to recommend a home sleep apnea test (HSAT) to a patient showing visible signs prevents additional steps, time and confusion. Patients tend to prefer the notion of being able to utilize an HSAT over a study that must be performed in a lab or facility. 

While in-lab screenings may be necessary for complex cases3, home sleep apnea testing devices are a preferrable option for many patients, saving time and money. Providing HSAT options in your practice will allow you to integrate this important step into your practice quickly and with ease.

Integrating Home Sleep Apnea Tests into Your Practice 

Those trained in sleep dentistry are uniquely qualified to help identify and care for dental patients with OSA. Although it is estimated that a staggering 1 in 15 Americans suffer from OSA, the majority of these patients remain undiagnosed2.

Dental patients seeking care may not know that their OSA diagnosis impacts their dental care or even that they have OSA at all. But, once you integrate OSA screenings into your practice, not only is it possible for you to work with other medical care providers, but you may also be able to offer specially fitted oral appliances that could serve as a more patient-friendly alternative to CPAP therapy, as recommended by the AASM4 and the AADSM.5

Providing OSA-diagnosed patients with this option could simultaneously benefit your practice and your patients by expanding your patient pool and revenue stream while maybe offering OSA patients a sleep apnea treatment option that they may find more comfortable and less noisy to use while sleeping. And, as sleep dentistry has become more prevalent, you have a variety of oral appliance companies with which your practice can partner and offer this kind of care.

Conclusion

According to leading field experts, integrating sleep dentistry into your practice can improve the specialized dental care available for the large number of patients suffering from OSA5. With disposable home sleep apnea test devices like WatchPAT® ONE, you can integrate OSA screening into your practice with a seamless solution that is accessible and super easy to use for your practice and patients.

References:

  1. Obstructive Sleep Apnea. American Academy of Dental Sleep Medicine. https://www.aadsm.org/obstructive_sleep_apnea.php
  2. Oral Health Topics – Sleep Apnea (Obstructive). American Dental Association. https://www.ada.org/en/member-center/oral-health-topics/sleep-apnea-obstructive
  3. Motamedi KK, McClary AC, Amedee RG. Obstructive sleep apnea: a growing problem. Ochsner J. 2009;9(3):149-153.
  4. Padma A, Ramakrishnan N, Narayanan V. Management of obstructive sleep apnea: A dental perspective. Indian J Dent Res. 2007;18(4):201-209. doi:10.4103/0970-9290.35833 
  5. Oral Appliance Therapy Should be Prescribed as a First-Line Therapy for OSA during the COVID-19 Pandemic,  Schwartz, et al.,  JDSM, Vol. 7, No.3 2020