MUSEUM DENTAL CENTER
Whether you are suffering from snoring, obstructive sleep apnea or sleep bruxism, we have the right solution for you. Our office is specialized in dental sleep medicine, if you have obstructive sleep disorder and you cannot tolerate the CPAP, using a customized dental appliance for sleep apnea and snoring can save your life.
Sleep dentistry is a fast growing field in the word of medicine. In this page, We will be discussing the topic of sleep disorders and the role of sleep dentistry in diagnosing and managing some of these disorders mostly by using sleep appliances know as Mandibular Advancement Appliances (MAD).
What is sleep?
Sleep is the restful state of body and mind to rejuvenate and replenish the energy we need to resume normal functions.
According to the Merriam-Webster dictionary sleep is “Is the natural periodic suspension of consciousness during which the powers of the body are restored”.
While Oxford dictionary defines sleep as “A condition of body and mind which typically recurs for several hours every night, in which the nervous system is inactive, the eyes closed, the postural muscles relaxed, and consciousness practically suspended”.
medicinenet.com defines sleep as “ the Body’s rest cycle, triggered by a complex group of hormones that are active in the main, and that respond to cues from the body itself and the environment”.
What are the stages of sleep?
Sleep is divided into 5 stages. The 5 sleep stages last a total of about 90 minutes and count as one sleep cycle. Normally, humans sleep an average of 7-9 hours or 5-6 sleep cycles per night.
Stage 1: light sleep where you drift in and out of sleep and can be awakened easily. In this stage, the eyes move slowly and muscle activity slows down. During this stage, many people experience sudden muscle contractions preceded by a sensation of falling.
Stage 2: Eye movement stops and brain waves become slower with only an occasional burst of rapid brain waves. The body begins to prepare for deep sleep, as the body temperature begins to drop a the heart rates slows.
Stage 3: Extremely slow brain waves called delta waves are interspersed with smaller, faster waves. This is what we know as deep sleep. It is during this stage that a person may experience sleepwalking, night terrors, talking during one’s sleep, and bedwetting.
Stage 4: Deep sleep continues as the brain produces delta waves almost exclusively. People roused from this state feel disoriented for a few minutes.
Stage 5: Rapid eye movement (REM) sleep, brain waves mimic activity during the waking state. The eyes remain closed but move rapidly from side-to-side, perhaps related to the intense dream and brain activity that occurs during this stage.
Infants spend almost 50% of their time in REM sleep while adults spend nearly half of sleep time in stage 2, about 20% in REM and the other 30% is divided between the other three stages. Older adults adults spend progressively less time in REM sleep.
The time people spend sleeping varies by age, a one week infant sleeps over 15 hours per day. Children 10-13 years old sleep about 10 hours day, and a 70 years old sleep between 5-6 hours per night.
Is there any relation between sleep disorders and Orofacial Pain?
There is scientific evidence that sleep disorders are associated with Orofacial pain. Patients suffering from chronic head and neck pain, often complain of poor or disturbed sleep resulting in a delayed onset or changes in sleep habits. A correlative relationship exists between sleep and pain; with sleep modulating pain and pain influencing sleep. During sleep, the perception of pain, as that of most sensations decreases. While a sleep disturbance can be a response to pain, it can also be a contributing factor by altering pain perception.
The musculoskeletal system is especially vulnerable to sleep deprivation. Disturbed sleep can contribute to several musculoskeletal pain conditions such as Orofacial muscle pain, myofascial pain, rheumatoid arthritis, low back pain, and mostly, fibromyalgia. Fibromyalgia, is a condition resulting in all over pain, fatigue and in 90% of patients reporting poor sleep.
The assessment of a patient’s sleep status should be part of a comprehensive evaluation for any patient with chronic musculoskeletal pain. Pain management through medications or physical medicine will provide relief and improve sleep. and conversely alleviate pain.
What are the types sleep disorders?
Sleep disorders are many, an over view of these disorders are discussed in the following paragraphs.
Dyssomnias: Patients who suffer with this sleep disorder are either too awake at night or too sleepy in the day. The most prevalent sleep disorder in this group is insomnia, other disorders include: obstructive sleep apnea, central sleep apnea, mixed apnea, Narcolepsy, restless legs syndrome and many others.
Parasomnias: These disorders are usually arousal disorders associated with transitioning from REM sleep to lighter sleep. These disorders include snoring, sleep bruxism, infant sleep apnea, sudden infant death and many others.
Sleep Disorders Associated with Medical or Psychiatric Disorders.
Sleep disorders are complex! Most patients with sleep discorders can be managed by a sleep physician, neurologist, and a dental sleep specialist, such as an Orofacial Pain Specialist. At our practice, we treat patients with the following sleep disorders: snoring, obstructive sleep apnea (OSA) and sleep bruxism. Snoring and obstructive sleep apnea will be explained in this page while sleep bruxism will be discussed in the Orofacial Pain page.
Do you know that Dr. Mohammad Khalifeh, DDS, MS, can help you get better night sleep?
This disorder may occur with or without secondary arousal of the snorer. If the sound is pharyngeal in origin, it is due to a narrow but patent airway and there is no cycling change in breathing efforts. Noise itself may cause arousal. Anatomy, upper respiratory track issues, obesity, sleep position and alcohol consumption are listed as possible causes.
The noise is due to loose tissue vibration associated with narrow but patent airways. It is calculated that snoring affect 30% of the adult population over the age of 30 and the Male: Female ratio is 2:1 with the gap closing after menopause.
Prevalence of snoring increases into the 6th decade and then decreases for older individuals snoring noise level is usually 50-70 DB & MAD (Mandibular Advancement Device also called dental sleep appliance used to manga snoring) reduces the snoring sound by 5-10 dB.
Obstructive Sleep Apnea (OSA)
What are the risk factors for Obstructive Sleep Apnea(OSA)?
– gender (male more than women),
– age (over 50), obesity(BMI over 29),
– high blood pressure,
– alcohol consumption,
– mandibular underdevelopment,
– adenoids and tonsils enlargement and
How does sleep apnea occurs?
– Reduced cross sectional area of the upper airway lumen due to excessive bulk of soft tissues or craniofacial anatomy.
– During inspiration negative pressure is generated in the lumen of the upper airway.
– Activity of pharyngeal dilating muscles becomes insufficient in OSA.
– Further reduction of activity in these muscles in REM sleep.
– Events termination may occur with or without arousal.
– Some events resolve with augmentation of muscle tone from chemical and mechanical stimuli.(3)
What are the diagnostic steps for OSA Sleep Disorders?
– Health history: Look for risk factors such as obesity, high blood pressure, diabetes, alcohol consumption, family history, etc.
– Clinical oral, head and neck exam. neck side larger that 16 in women and larger that 17 in men good indicators for developing OSA. Large Tongue size, large tonsils, teeth showing evidence of acid reflux also indicate high possibility of OSA
– Sleep questionnaires such as Epworth Sleepiness scale.
– Home or sleep center testing for OSA using special equipment called Polysomnography (PSG). This device is capable of recording brain activity (EEG), Muscle activity (EMG), heart activity (ECG), air flow, CO2 level, O2 level, heart rate, eye movement (EOG), chest and abdomen effort, etc.
Nox T3 Sleep Monitor
Mallampati Airways Classification
Cervical teeth erosion caused by acid reflux and / or bruxism
How obstructive sleep apnea and snoring are managed?
Snoring and OSA share the same management technique, the goal is to open the airways and help non-resistant air flow to and from the lungs. The following are among many suggested ways to help patients with OSA or snoring:
– Treat the cause if possible, control the high blood pressure, reduce the weight, and alcohol consumption especially at night, exercise to help increase the neck muscle tone, sleep on the side rather than on the back. If the nose is clogged, use decongestants etc.
– Surgical treatment to remove any physical obstructions such as tonsillectomy, adenoids removal, tongue reduction, Uvulopalatopharyngoplasty (UPPP) surgery and Orthognathic surgery to open the upper airways.
– Upper airways stimulation using subcutaneous implanted devices.
– Nasal or oral Continuous Positive Airway Pressure (CPAP) and (APAP), This sis the golden stander for managing OSA for most cases.
– Mandibular advancement devices (MAD) also called Sleep Appliance Therapy or Dental Sleep Appliance, this devices are considered very convenient and are great alternative to CPAPs in patients with moderate to severe OSA.
What are the risks of not treating OSA Sleep Disorders?
OSA if not treated can cause any of the following:
– Daytime drowsiness which is a big risk for causing motor accidents.
– Heart attach.
– Memory loss.
– Early death.
– Sleep bruxism (Clinching and grinding teeth while sleeping).
There is strong scientific evidence that patients with snoring or obstructive sleep apnea (OSA) get great help by using oral sleep appliance called Mandibular Advancement Device (MAD). Dental sleep appliance is a great alternative to C-Pap for patients who cannot tolerate the CPAP.
How dentists can help patients with OSA Sleep Disorders?
– Recognizing the problem
– Educate the patients
– Refer or manage the problem (sleep appliance such as mandibular advancement appliance are usually used to improve the airways in patients with obstructive sleep apnea and snoring)
– Follow up
– Young T, Palta M, et al. The Occurrence of Sleep-Disordered Breathing Among Middle-Aged Adults. N Eng J Med; 328: 1230-35
– Senaratna CV et al, Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev.2017 Aug;34:70-81. doi: 10.1016/j.smrv.2016.07.002. Epub 2016 Jul 18.
– International Classification of Sleep Disorders 3rd American Academy of Sleep Medicine, 2014