In recent years I have become impassioned with the study of ‘dental sleep medicine, the management of obstructive sleep apnea. On reflection, I have treated many of the symptoms of apnea for years without ever recognizing the origin or the significance. It has been a humbling experience.
Why would a dentist be involved with apnea therapy? After all, we just fix teeth. You would be mostly correct if you were of this opinion and few dentists would disagree, spending the bulk of our time, effort and resources developing our dental restorative skills, often to extremely high levels of proficiency. Whiter, straighter, stronger, with greater precision, speed and relative comfort than ever before, the demand for better esthetics and function increases constantly. We are fortunate to live in an era where the loss of a tooth is becoming a less common event and prevention of oral disease the new standard of care.
There is, however, the occasional patient who just doesn’t seem to fit the common pattern, whose teeth are so badly damaged from grinding or acid erosion that they may require total dental reconstruction. An expensive proposition and a technically challenging project, even for an experienced and well trained dentist. A boost to production statistics: A nightmare to maintain: A potential public relations disaster. You see, much of our training involves the treatment of the symptom and not necessarily the identification of the cause.
The fact of the matter is that severe attrition or wear of the teeth from nocturnal bruxism (grinding of the teeth while asleep) is very highly correlated with an unmanaged sleep breathing disorder such as sleep apnea. It is now believed to be a subconscious effort by the brain to increase the muscle tone of the pharynx and open a collapsed airway. Other factors may certainly be involved such chronic pain, disrupted sleep patterns and emotional issues, but the ability to maintain a viable airway will trump. We tend to treat bruxism and tooth wear with a ‘night-guard’, which may slow the rate of wear to the teeth, but may actually increase grinding and apnea if present. Then we fix your teeth. Two years later we fix them again and the pattern keeps repeating, all because you can’t breath properly at night.
A dentist may also notice severe tooth damage caused from acid erosion secondary to diet habits, bulimia, etc. in young people and is often easily recognized. What may not be so obvious is esophageal reflux disease or GERD usually attributed to diet in older people and treated with medication. The dentist may see eroded cusp tips of teeth and think bruxism, or may astutely recognize the signs of acid erosion, then still treat the symptom by restoring the teeth. After all, acid reflux is the physician’s problem, not mine….I think. GERD is correlated with unmanaged apnea at a rate of 70%!
I’m going to throw in another predictor of obstructive sleep apnea you may be able to see yourself and that is the presence of a ‘scalloped tongue’. Stick you tongue out and look at the edge. Regular indentations, or scalloping, of the border is 70% predictive of obstructive sleep apnea and virtually none of your health care providers will know this. Don’t wait for a premature heart attack or stroke to look in the mirror for this one.
I mentioned in my opening paragraph how humbling the study of dental sleep medicine was for me. I want to believe myself to be a conscientious and progressive thinking dentist, yet I have been guilty of performing repeated restorations for the same patient, again and again, due to ‘grinding’ and in spite of my ‘mouth-guard’. I have dutifully updated medical histories and recorded the addition of prilosec or nexium to a medication list without asking myself ‘why?’. I have seen a thousand scalloped tongues and thought they were kind of interesting. I never dreamed that these people may be dying a little bit every night because they can’t breath. Quite simply, we are taught to treat the symptom and not the cause. No excuse. It is just the fact.
There is some very good news, however, in that sleep apnea can now be very comfortably and effectively managed in many patients with oral appliance therapy provided by a properly trained dentist. An oral airway dilator device which looks similar to orthodontic retainers and designed to gently move your lower jaw forward while you sleep has proven to work exceptionally well, especially in mild and moderate apnea cases, so you don’t have to be afraid of the breathing machine (CPAP) any more. Look for a dentist who at least belongs to a dental sleep medicine academy such as the AADSM or the ACSDD and ideally has special training in the form of a Diplomate credential in one of these groups. There are only of few of us in AZ and don’t be fooled by a dentist offering a ‘snore guard’. It is not the same as actual apnea management.
In summary, if you suffer from excessive clenching or grinding of the teeth, excessive tooth wear, acid reflux disease, or if your tongue looks as if it has been trimmed with pinking shears, you should include sleep apnea in your list of differential diagnoses. These symptoms are less obvious, but no less significant than the classic symptoms of apnea which include heavy snoring, long pauses in breathing while asleep followed by gasping or choking for breath, non-restful sleep, excessive fatigue and high blood pressure. Also, don’t be surprised if your physician or your dentist has yet to make the connection between these symptoms and don’t be afraid to ask questions.
Contact SleepEffect if you are at all concerned and see if SleepEffect may help you to sleep better and live longer, not to mention saving those beautiful teeth.