Sleep Apnea & Dentistry: The Ultimate Guide

Dr. Kyle Hornby

Hi, I'm Kyle Hornby and I'm a Kitchener-Waterloo Dentist.

Every week I write about 2-3 dental issues and answer commonly asked patient questions to help improve the dental content available to the public. This week, I'd like to provide information on obstructive sleep apnea (OSA) and how it negatively affects your teeth, gums, jaw and overall health.

Now, this is a comprehensive guide so I'll include a table of contents here so you can jump around to different topics if you'd like:

What is Sleep Apnea?

Sleep apnea is a disorder whereby you stop breathing during sleep. Apnea can be due to an interruption in the brain signals that drive unconscious breathing (this is Central Apnea) or because your airway collapses as you sleep (this is Obstructive Apnea). Most people are not aware of the interruptions or disturbances in sleep that come with sleep apnea. Many however, will experience hundreds of these interruptions each night.

Is Sleep Apnea a Problem?

Obstructive Sleep Apnea (OSA) affects about 26% of the North American adult population. OSA is linked with excessive daytime sleepiness, diminished quality of life, increased car accidents, decreases in cardiovascular health, gastric dysfunction and many other adverse health outcomes. Obstructive Sleep Apnea can have many dental health consequences too, and this positions your Dentist as somebody who can catch sleep apnea early on.

So, who tends to get sleep apnea?

Who is at Risk for OSA?

OSA is correlated with increased age and a higher body mass index (BMI). However, this has led to an unfortunate assumption that you have to be older and obese to suffer from OSA. This is absolutely not the case.

Many of our patients that suffer from obstructive sleep apnea are in fact young, lean and otherwise healthy. They often have a larger tongue that occupies an elevated position in their mouth. When we look at patients with OSA, often times you can't see past their tongue to the back of the throat. As you can imagine, when they lay down to sleep at night, gravity pulls their tongue back even further and it covers their airway.

Because we look inside people's mouths all day, Family Dentists are in a perfect position to screen people for obstructive sleep apnea. There are many things we can observe (I'll go through these things in this article, shortly) that will trigger suspicion that our patient might suffer from OSA. From there, we can recommend sleep tracking apps and refer our patients for sleep studies. A sleep study is currently the gold standard for diagnosing Obstructive Sleep Apnea.

So, what signs might Dentists see that make us think you might suffer from sleep apnea?

Let's go through some of them, now. From there, I'll discuss how OSA can negatively affect your oral and overall health.

What does OSA sound like?

Well, often times Obstructive Sleep Apnea doesn't sound like anything. It may involve an instantaneous collapse of your airway which leads to a micro-disturbance or awakening. In some individuals, as the airway narrows, they may snore which can be very loud and noticeable to others.

If you hear your partner snoring, let them know and suggest that they tell both their Dentist and Family Doctor.

Oral Signs of Obstructive Sleep Apnea

So what do we see as Dentists that trigger us to screen for Obstructive Sleep Apnea?

Here's a list of some readily available signs that we can see in the mouth during your check-up...

Large Tongue with a High Vertical Position

When we think of sleep apnea and disordered breathing it helps to think of our airway as a tube. If the tube's open, air can flow through. If we put a cap on the tube, it reduces or prevents air flow.

A decrease in air flow is what happens when people snore.

An interruption in air flow means we can't breath. This is what happens when people experience an episode of apnea and wake up temporarily.

(The tricky part about Obstructive Sleep Apnea is that these small, short awakenings don't allow you to gain consciousness. Therefore, most people have no idea that they're sleep is interrupted, sometimes hundreds of times each night.)

Now, back to thinking about our airway as a tube. When we lay down, our tongue falls back in our mouth. Also, our lower jaw slides back toward our pillow and the muscles attached to the lower jaw relax. When these muscles relax, they can block your airway. When your tongue slides back in your mouth, it can block your airway.

If you're tongue is larger than average and occupies a high position in your mouth, it's already blocking a portion of your throat and therefore, your airway. When you lay down at night, full airway blockages are very likely.

A blocked airway means brief awakening and an instance of interrupted sleep.

Your Dentist can take a quick look in your mouth and assess whether your tongue size and position put you at risk for Obstructive Sleep Apnea.

Nighttime Tooth Grinding (Bruxism)

The correlation between nighttime tooth grinding and sleep apnea is very high. Many experts believe that the jaw movements seen during tooth grinding are a reflex used by your body to try to open your collapsed airway. Movement of your jaw forward (or in an upward direction when you're laying down) can open your airway.

Other experts suggest that the sudden increase in blood pressure seen during a sleep disturbance or awakening triggers muscle hyperactivity, especially in the jaws.

In my practice, if I observe heavily worn, chipped teeth, dental fillings and crowns in a patient the first thing I do is to look at their tongue in relation to their throat and airway. Can I see their throat? Does their tongue appear to fill their entire mouth? These are signs that they might experience a collapsed airway during sleep.

I'll also ask the patient how they sleep at night? Are you tired most mornings? Are you a restless sleeper? In the majority of cases, a patient will report that they don't sleep well. Sometimes, I even get "oh, I'm a terrible sleeper...just terrible". These are people that I start to talk to about seeking a sleep study.

Acid Wear & Signs of Reflux

There is mounting evidence showing a link between obstructive sleep apnea and Gastroesophageal Reflux Disease (GERD). When the airway collapses many times through the night, the air pressure changes within your esophagus. This may allow stomach acid to move to upper portions of the esophagus and even the mouth. This stomach acid can cause erosion of your enamel.

If you grind your teeth in these acidic conditions, you can destroy tooth enamel and dentin very rapidly.

As a Dentist, if I see signs of nighttime grinding plus acid erosion, I'm thinking there's a high chance of OSA in that particular patient.

So, now that I've discussed some of the signs that can inform your Dentist you might suffer from OSA, I'd like to explore how the condition can negatively affect your dental and systemic health.

Sleep Apnea and Health Consequences: How Sleep Apnea Affects the Body

Sleep Apnea, Mouth Breathing and Dry Mouth

We see lots of people that breath through their mouth at night and people are commonly self-aware that they do this. They will note that they wake up with their mouth wide open and that their mouth is very dry. Many will also know (by way of being informed by their spouse/partner) that they snore.

So, why does this matter?

Well, research has shown that during mouth breathing, our airways have a smaller cross-sectional area and the muscles that stretch our airway open are more relaxed. Typically, OSA is more severe in mouth breathers.

Mouth breathing dries out the mouth and changes the overall oral environment. This altered environment affects which microorganisms thrive and proliferate, altering the overall balance between good and bad bacteria. Unfortunately, a dry mouth favours a greater percentage of harmful bacteria.

In fact, a dry mouth allows for harmful bacteria to thrive. These are the "bugs" that cause tooth decay and gum disease. A dry mouth also favours the proliferation of bacteria that feast on dead tissue cells and produce the sulfur-based compounds that cause bad breath.

In addition, a dry mouth means low saliva flow and saliva is what supplies Calcium and Phosphorus to re-mineralize (strengthen) your enamel as you sleep. And, research has even shown that drier mouths tend to be more acidic and this favors erosion of your tooth enamel.

Sleep Apnea and Tooth Grinding

Above, we talked about tooth grinding as a trigger sign of possible OSA. Many believe that grinding and related jaw movement is a reflex to open your airway during apneic episodes. Well grinding can break teeth, fillings, dental crowns, dental bridges and dental implants. Grinding can wear down your tooth enamel and it can cause jaw or TMJ soreness and dysfunction.

Generally, tooth grinding causes a lot of structural damage around the mouth and jaws.

While most Dentists recommend night guards to help limit damage done by tooth grinding, some patients may benefit more from treating their OSA with an oral appliance or CPAP machine. Eliminating sleep apnea has been shown to reduce frequency and severity of nighttime tooth grinding.

Sleep Apnea and Systemic Health Problems

Sleep apnea has been linked to a multitude of serious health issues. Here is a list of them:

  • Cardiovascular and Cerebrovascular diseases
  • Hypertension/High Blood Pressure
  • Cardiovascular Emergencies
  • Metabolic Disease/Diabetes
  • Renal/Kidney Disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Cancer Mortality

There has also been a great deal of research showing a relationship between obstructive sleep apnea and attention deficit hyperactivity disorder (ADHD) in both kids and adults.

How is Obstructive Sleep Apnea Diagnosed?

The gold standard for sleep apnea diagnosis is Polysomnography, which is a type of "sleep study". During this test, they will hook you up to a variety of monitors to keep track of brain, lung and heart activity, breathing patterns and blood oxygen levels while you sleep. Your Dentist or Doctor may also refer you to an Ear-Nose-Throat (ENT) Specialist to rule out other causes of airway blockage.

Some sleep clinics may offer the option of setting you up for an at-home sleep study. For many, this is a convenient way to get the answers they need while being able to sleep in a comfortable and familiar place.

Treating Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea occurs because the airway collapses/closes during sleep. Not being able to breath triggers sleep disruptions and awakening. So, how do you keep your airway open?

Oral-Dental Apnea Appliances

Your Dentist can make you an oral appliance that will help to hold your lower jaw forward during sleep. Your lower jaw attaches to a series of bones, tendons and ligaments that, when in the right position, can stretch or pull your airway open. Typically, protruding the lower jaw (moving it forward) helps to open the airway. Of course, when you sleep, gravity pulls your lower jaw back toward your pillow and that can cause airway collapse. An oral-dental apnea appliance can keep your lower jaw from sliding back during sleep, thus preserving your airway and the ability to breathe.

Importantly, these dental apnea appliances work well for individuals with mild OSA. They tend not to help patients with moderate - severe forms of Obstructive Apnea.

That brings us to the next treatment option for OSA...

The Continuous Positive Airway Pressure (CPAP) Machine

The CPAP machine is the most effective treatment for moderate to severe cases of Obstructive Sleep Apnea. This machine sends a pressurized stream of air through the mouth, nostrils or both to keep your airway open, thus preventing airway collapse.

CPAP machines certainly take some getting used to but, luckily, there are many options and designs available. CPAP machine masks can cover the mouth alone, nose-only or some designs will cover both. Here are a few options:

Full-Face Mask. This is one of the more bulky and cumbersome designs. The mask covers the mouth and nose, delivering high-pressure air through both. The masks are for people who suffer from chronic nasal congestion (i.e. due to allergies) or who breath through their mouth.

Oral Mask. These masks attach and seal around the mouth. No air is delivered through the nostrils. These masks are much smaller than are full face masks. They are better suited to patients who breath through their mouth under normal conditions and who suffer from chronic nasal congestion which may prevent airflow from a full- or nasal-mask.

Nasal Mask. Most nasal masks are triangular in shape and cover the entire nose. They deliver air through the nose only. They are fairly compact compared to full-face masks but are suited only to patients who commonly have clear nasal passages. These masks can cause considerable irritation around the nose and on top of the nose bridge for some patients. These patients may prefer the nasal pillow mask.

Nasal Pillow Mask. Nasal pillow masks are compact and deliver air through the nostrils only. They seal at the nostrils and do not extend around your entire nose. People with clear nasal passages benefit from these masks and tend to find them more comfortable compared to a full nasal mask.

Home Remedies for Sleep Apnea

So there are always things we can do non-invasively to improve any given medical condition, disease or syndrome. Sleep apnea is no different. Will sleep apnea go away with the right changes? Maybe not but we can certainly improve our overall health with a few tweaks and reduce the impact that sleep apnea has on our lives.

So, home remedies won't typically be enough to rid you of severe sleep apnea but they may help turn severe apnea to a more moderate form. In some cases, these strategies can eliminate snoring or dramatically improve mild apnea.

Here they are:

Minimizing Alcohol Intake. Alcohol relaxes your muscles. It can relax the muscles that act to keep your airway patent and open as you sleep. The muscle relaxation that comes with alcohol consumption can bring on snoring or even airway collapse during sleep.

Staying Off Your Back. I love sleeping on my back. I find it gives me my most restorative sleeps. However, sleeping on your back means your muscles have to fight gravity to keep your airway open at night. For people with snoring issues and mild OSA, sleeping on their side may help their jaw to stay in a more forward position which helps attached muscles to keep their airway open.

Getting Lean. There is research showing that weight loss can make obstructive apnea less severe while improving treatment outcomes with oral appliances and sleep apnea machines. Sometimes, additional mass around the neck can increase force against the airway when we lay down. Keeping more lean around the neck may improve your response to apnea treatment by relieving some of the force against your airway when laying down.

Toning Muscles Around you Airway (Myofunctional Therapy). If your airway is narrowing (causing snoring) or closing (causing OSA), then increasing muscle tone around your throat and airway can help to keep you breathing at night. Often called myofunctional therapy ("myo" is just medical terminology for muscle), these exercises have been proven to reduce or eliminate snoring and help to reduce the severity of mild - moderate obstructive sleep apnea.

Here are a few good ones:

  1. Tongue Slide. Push your tongue against the inside or back of your upper front teeth. Maintain pressure while sliding your tongue backward toward your throat along the roof of your mouth. Repeat 10 times. Result: Strengthens and tones your tongue and throat muscles.
  2. Tongue Push Up. Push the entire top surface of your tongue up against the roof of your mouth and hold under pressure for 15 seconds. Repeat 10 times. Result: Strengthens and tones your tongue and palatal muscles.
  3. Tongue Push Down. Push your tongue against the inside of your lower front teeth and then slide your tongue backward across the floor of your mouth. Repeat 10 times. Result: Strengthens and tones tongue and soft palate muscles.
  4. Cheek Hook. Use your right index finger to gently pull your right cheek and lip out laterally. Then, use your face, lip and cheek muscles to pull your lip and cheek back into place. Result: Strengthens and tones muscles of lips and cheeks - this will help to maintain mouth closure during sleeping. A closed mouth means breathing through your nose and lower incidence of airway collapse.

Take Home Messages about Obstructive Sleep Apnea

The article above is a lengthy one but my goal is to provide as much info as I can about a serious and widely underdiagnosed medical condition. Sleep apnea is linked to many serious health conditions and it deprives you of the recharge time your brain and body need through the night.

Apnea can also lead to serious dental issues like grinding your teeth which causes damage to teeth and expensive dental work and it can increase gum recession and TMJ dysfunction. Because these issues are easy to see in and around the mouth, your Dentist is very likely in the best position to screen for sleep apnea and other nighttime disturbances. This is no slight to Physicians but they typically don't screen for apnea or ask patients how they're sleeping at night. Also, many patients with yet-to-be-diagnosed apnea report sleeping well as they're not aware of their awakenings and micro-disturbances. This means that asking patients about their sleep quality won't always yield accurate information.

You can have your sleep patterns evaluated at a sleep clinic and they can advise you as to whether you suffer from OSA or not. From there, the severity of your sleep apnea will determine management.

Mild to moderate apnea cases may benefit from Oral Appliances, myofunctional exercises and other lifestyle changes. More severe cases of apnea are often treated with a CPAP machine.

Oftentimes, patients who receive treatment to alleviate their apnea will decrease tooth grinding (or stop altogether). Treatment will also help them to stop mouth breathing, a habit that can negatively affect the bacteria balance in the mouth leading to serious dental health consequences.

Ultimately, catching sleep apnea early and seeking treatment can help to reduce the risk of negative health consequences and ensure you're getting the rest your body needs on a daily basis. Proper assessment and treatment can improve your mental state and potentially add years to your life!

Thanks for reading,

By Dr. Kyle Hornby, Dentist in Kitchener, Ontario

Our Dentist Office in Kitchener is conveniently located Downtown. We are a short drive away for families in Waterloo, Breslau & St. Jacobs. Our central location means we truly offer family dentistry near you!

This article is not intended to be a substitute for professional advice, diagnosis, or treatment. Accordingly, always seek the advice of your Dentist or other healthcare providers regarding a dental condition or treatment.

Enjoy a fresh start.
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