By Steve Carstensen, DDS 

Patients come to our dental offices with some common complaints related to poor breathing and oral inflammation…dry mouth…bad breath…gingivitis…excessive wear on teeth. They ask us to help them.  

One of the things we can do for our patients is to be curious about whether they have intermittent hypoxemia that is diagnosable and treatable. I caution us to be aware of having too narrow of a focus. When someone presents with jaw pain, wake-up headaches, and tooth wear, we tend to think they need a supporting nightguard. I think we should be curious about what else might be going on. 

I ask my patients about snoring. I ask them if they have been diagnosed with a breathing disorder. I wonder if they should be using CPAP before I make a bite splint. If you make a splint, they may come back and report they don’t like the splint, which may be because it interferes with their breathing. So, I recommend we stay curious, and when we do make a protective guard for their teeth, we ask more questions. Make sure the diagnosis we make not only correlates with the symptoms, but the patient responds well to the treatment we provide.  

How can we help our patients’ breathing physiology? We can help them be better breathers. There are oral appliances that keep the jaw from falling back and crowding the airway but what about the daytime? It turns out that people who breathe “badly” during the day develop breathing behaviors that the brain continues during the night, and these behaviors are inefficient for keeping the airway open during sleep. So, if we help our patients breathe better in the daytime, we set their brains to be more capable of handling airway disruptions during sleep.  

If you’ve read the book Breath by James Nestor, you will learn about the daytime problems translating into nighttime problems and that nose breathing is best for our physiology. I am a huge nose breathing fan. There are electrical signals that pass from specialized cells in the nose directly to the limbic system which influences our autonomic nervous system. It filters sensory signals from the rest of the body and sends proprioceptive signals into the cortex and down into the autonomic nervous system. None of these brain-signaling signals happen with mouth breathing. 

If you ask someone, “How is your nose breathing?” They will say, “Fine,” because you are the dentist, and they think that is a strange question. They also are accustomed to the amount of work it takes to breathe through their nose, so they don’t really know if they breathe through their nose well enough. The way to test is to ask them to close their lips and put their finger over their lips for two minutes and breathe calmly. With the finger over their lips, they are unlikely to have difficulty breathing through their nose but if they start breathing faster this is a sign of stress. If their heart rate goes up, if they know it was tough for them to do, there is something interfering with their nose breathing. It might be a deviated septum, allergies, a head cold or chronic rhinitis—but something is wrong.  

Knowing this is handy when we are planning to do restorations. You won’t use a rubber dam if they can’t breathe through their nose, or you will schedule to do the restorations after they’ve been medicated. I have found that Afrin is good for clearing the nasal passages before dental treatments. Short-term help is good but stay curious about how often they cannot breathe through their nose, and help them. 

By Steve Carstensen, DDS 

I want to share a clear example of how bad sleep directly affects the anatomical structures dentists pay a lot of attention to—the mandibular condyles.  

Sleep Disruption Disrupts Bone Regeneration 

We’ve all seen on X-rays condyles that do not look healthy. We wonder what causes so much degeneration. There are shelves of books and whole courses about what goes wrong but one of the things that affects condyles is a circadian rhythm disruption. Research* with rats has demonstrated that sleep disruption disrupts bone regeneration, causing thinning of the condyles. 

* Corrigendum: Circadian rhythm protein Bmal1 modulates cartilage gene expression in temporomandibular joint osteoarthritis via the MAPK/ERK pathway. Chen G, Zhao H, Ma S, Chen L, Wu G, Zhu Y, Zhu J, Ma C, Zhao H.Front Pharmacol. 2022 Sep 8;13:971840. doi: 10.3389/fphar.2022.971840. eCollection 2022.  

Rats were interrupted from their sleep cycles so they could not get through a normal night’s sleep. After eight weeks they took the disruptions away. During the first four weeks the cartilage layer over the condyles thinned, became really thin at six weeks, and stayed that way across eight weeks. After they returned the rats to undisrupted sleep for four weeks, the breaks in the normal covering of the condyles were still there.  

What do we take from that? The earlier in life that we establish healthy physiology that supports healthy sleep, the greater the chance children have of growing human condyles to withstand TMJ problems later.  

Disrupted Sleep Contributes to Multiple Health Issues 

There’s a lot of research that points to poor breathing contributing to pediatric and adolescent health issues. Among these issues are neurological deficits, behavioral problems, poor school performance, and pulmonary hypertension. A primary cause of poor-quality sleep among our youngest patients is enlarged tonsils and adenoids that obstruct their airway.  

Helping Children and Teens Breath and Sleep Better 

What can dentists do in daily practice with children and teens to help them breathe better and sleep better early in life?  

1. Educate our adult patients who are parents of children to be aware of signs and symptoms.  
2. Develop a culture within our practice of being a health consultant, so our adult patients feel welcome to easily engage in conversations about health issues that commonly affect children and teens.  
3. Introduce the parents to their own need for an open airway for healthy sleep to raise awareness.  
4. Assess all our patients for breathing issues and examine their airways for signs of obstruction.  
5. Provide guidance to our adult patients and to the parents of the young people in our care so they can choose appropriate care.  

Our Responsibility 

We need to start paying attention to these things as much as we do the health of the teeth and periodontium. As dentists, we are responsible for the entire cranial facial respiratory complex. My colleague, Dr. Kevin Boyd in Chicago, is a pediatric dentist who came up with that label a few years ago. I love that term, because it helps us focus on the whole person, structure and function! We can be proud when we help our patients with the respiratory part of the complex. 

As we take our place in medicine as being in charge of the cranial facial respiratory complex, we get to affect growth and development. We get to help train the body to swallow properly and grow good bone and good airway support. And that’s the major role I think dentists are going to have going forward in healthcare–identifying those children who have an underdeveloped cranial facial respiratory complex and influencing their care. Like other folks in medicine…an ENT doctor…a myofunctional therapist…a speech therapist, we help correct the things that we recognize that are going wrong. 

By Steve Carstensen, DDS  

“Hypoxic burden” is the challenge that the body has to low levels of oxygen on an intermittent basis. Our physiology has an adaptive capacity to manage hypoxic burdens. We can hold our breath. We can dive under water. We can go up in an airplane. We can live at different altitudes. When that adaptive capacity is exceeded, low oxygen places our physiology under stress. At the extreme level, organs are injured. Frequently occurring or sustained hypoxic burdens at lower levels lead to chronic disease conditions. These are chronic non-infectious diseases of inflammation. 

As people sleep most keep their airway open. Whether they are on their backs or on their sides, they have an open airway and breathe through their noses. But 29 millions of us in the United States have some form of obstruction in their airway while they sleep. The general term for all levels is sleep-related breathing disorders. At the most serious level we call it obstructive sleep apnea. 

Many of our patients have daytime breathing problems as well but during sleep a large percentage of our patients have intermittent hypoxia because their tongue occludes their airway and their oxygen levels drop. The brain kicks in when the body exceeds its adaptive capacity and wakes the patient up. Their physiology is under stress. They are not getting a restful night of sleep.  

The Size of the Problem 

Millions of people have some form of sleep related breathing disorder. The American Academy of Sleep Medicine commissioned Frost & Sullivan to do a study in 2016 that calculated the annual economic burden of undiagnosed sleep apnea among U.S. adults as approximately $149.6 billion (about $460 per person in the US). The estimated costs included $86.9 billion (about $270 per person in the US) in lost productivity, $26.2 billion (about $81 per person in the US) in motor vehicle accidents and $6.5 billion (about $20 per person in the US) in workplace accidents. There is no dispute about the size of the problem, but even the best efforts of dentists working in tandem with sleep physicians have not addressed the volume of people who would benefit from care. 

Currently there is a shortage of Sleep Medicine specialists. The recent approximation is 7,500 but not all are practicing. Even if there were 10,000 diagnosing physicians, it is a small number compared to 193,000 practicing dentists. There is a consensus of leaders in the field who think there are a few thousand dentists actively treating sleep-related breathing disorders, but maybe only a few hundred delivering a significant number of devices per year. There need to be many more. We can incorporate airway assessment and patient education into our workflow to support the breathing and airway health of our dental patients. We can add more services to our practice mix to address their needs within our licensure. So, I am on a mission, if you will, to take this challenge to my Pankey Institute colleagues through a series of blogs and educational opportunities, starting here and in presentations during the Essentials continuum. 

The Consequences of Sleep Fragmentation 

During a normal night’s sleep, we’re supposed to go through cycles of light sleep, deep sleep and dream sleep (REM sleep). If you have a new baby, a new puppy or breathing disorders and your sleep is interrupted frequently because of these things, you’re not going to get a good night’s sleep. When fragmented sleep is created by a breathing-related sleep disturbance, we have cycles of apnea and arousals—intermittent hypoxia that leads to health problems.  

Our patients may not call it sleep fragmentation. They may say I get terrible sleep. If they are not able to breathe well through the night every night for decades, there are pathophysiologic consequences. The worst are systemic inflammation, adrenergic activation, and oxidative stress. If the human body responds to chronic intermittent hypoxia after the adaptive process is exceeded, the body starts to break down. Manifestations include insulin resistance, hypertension, Type 2 diabetes, heart failure, atrial fibrillation, stroke, non-alcoholic liver disease, chronic kidney disease, cancers, and polycystic syndrome.  

The respiratory system manages gas exchange in our bodies. It is the foundation of our physiology. We disrupt that and we allow the body to develop these other issues. Our patients complain they have had difficulty having these diseases diagnosed and treated. But now we have ways to intervene to prevent these problems upstream. We can do that as dentists.  

Breathing and airway support is a powerful place for dentists to impact the whole-body health of those we serve. 

Dentists make thousands of choices during their careers. From practice style to how to shape retirement plans, we get to decide how to do things. No matter what style of practice the dentist chooses, the mix of services the involved dentist gets to pick from is ever expanding. Dental sleep medicine is one of the newest services we have added to the list and many dentists are curious about adding it into what they already do.

Practicing Dental Sleep Medicine

Dental sleep medicine may be the closest thing to practicing medicine any non-oral surgeon dentist will get. Managing a chronic disease – sleep disordered breathing – is much like managing another one, periodontal disease. More and more dentists every day are taking up the challenge of helping their patients breathe better during sleep.

Membership in Dental Sleep Medicine organizations, like American Sleep and Breathing Academy, has grown by double digits each year. The calendar is crowded with courses on how to make oral appliances. Dentists are finding the rewards that come with this area of practice energizing and fun. Whole office teams are being reshaped to learn new skills.

Dentists are taught some medical basics during professional school, but years of concentrating on what we do for oral health can dilute the attention paid to patient health history, pharmacology, and medical comorbidities.  

Since every sleep disorder is a medical diagnosis, collaboration with medical professionals requires the dentist to revisit whole body health and recover the ability to communicate with physicians with appropriate detail. Patients certainly expect their dentist to understand their diagnosis and treatment strategies.

Once the person is diagnosed with sleep disordered breathing, treatment choices include positive air pressure masks, surgery, and oral appliances (mostly mandibular advancement devices). Dentists must have a working knowledge of each of these strategies, especially as we are relied upon for expert application of the third choice. Advancing the mandible to open the airway is the description of what we do, but the implications of that choice involve every bit of scientific based health knowledge dentists know. Incorporating sleep dentistry into your practice can bring new learning and new energy to your practice at the same time that you significantly improve the health and quality of life of your patients.

For more information join Steve at the Dental Sleep course.

It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed. Integrating dental sleep medicine into your practice can be a great way to engage your self and your team and serve your patients in a powerful way that will improve their overall health.

Dental Sleep Medicine Involves the Whole Team

Adding dental sleep medicine to your mix of services requires the entire team to gain new knowledge of the role of sleep and the diagnosis of a sleep breathing disorder, as well as how we can utilize dental devices as an adjunctive therapy. This has to be combined with ‘dental’  concerns such as muscle pain, temporomandibular joint disorders, missing or loose teeth to finalize a treatment recommendation. Working through complex multi-factorial diagnostic and treatment planning decisions is part of practicing dentistry, and we simply apply these skills to the additional medical information that is pertinent for patients with a sleep breathing disorder.

When any new service or technique is added to our daily repertoire in a busy dental practice it can cause disruptions, stress, and challenges that some dental teams won’t be able to see past to get the rewards that come from all the hard work. In addition to acquiring the technical expertise make sure you have prepared your team, and you may benefit from expert advice and finding meaningful mentors that can assist you.

A complicating factor for many offices is the choice to submit sleep therapy to medical insurance. Most dental offices are not equipped for medical billing and many financial administrators, perfectly comfortable with dental claim forms, find themselves mystified at the nuances of submitting to a host of unfamiliar payers. Fortunately, professional medical billers have stepped up to help, but even making this agreement requires dentists to stretch their knowledge and get expert advice in new areas of healthcare.   

Choosing Dental Sleep Medicine

Why do this? While dentists often improve people’s lives in fantastic ways with pain relief, reducing infection and inflammation, and beautifying smiles, rarely do we have the opportunity to give them a chance to live longer. Obstructive sleep apnea left untreated is proven to shorten life expectancy.

Treating the disease will enable people with persistent hypertension to reduce their blood pressure. Bed partners of snorers whose airways are opened improve their quality of life. Often married partners who had chosen to sleep separately reconcile into one bedroom. When someone sits with our team and tells us how much better they enjoy dreaming again after years of missing it, our days are brighter!

Are you trying to decide if treating sleep-disordered breathing is right for you? Dental continuing education provides plenty of introductory courses. I’m honored to be the editor of Dental Sleep Practice Magazine, dedicated to practical education.

There are academies and associations dedicated to supporting every member of the dental team as we expand our medical involvement to provide a service that only dentists are capable of performing. Mini-residencies are forming at leading educational institutions to provide in-depth, multi-disciplinary learning.

Is it worth the effort?

The first time your team celebrates together after a happy patient gives everyone a hug because of how much better they feel now that they’ve used your oral appliance, I think you’ll know the answer.