Sleep Bruxism is a condition that is receiving a tremendous amount of attention of late in the news. Perhaps as a result of the number of dentists who are providing high level diagnostics using a medical grade sleep bruxism monitor to collect surface EMG data. This kind of objective data has opened the opportunity to improve speed to treat for patient with jaw symptoms. Patients who clench and grind do not all generate pain or present with a jaw pain complaint in fact they may be unaware that they suffer from sleep bruxism. Often this underlying disease is associated with sleep disordered breathing and should be objectively evaluated and measured to better evaluate the severity of the condition and to rule out obstructive sleep apnea and related sleep disordered breathing.-ed
BRUXISM THERAPY AND OBSTRUCTIVE SLEEP APNEA THERAPY FOR EVERY DENTAL PRACTICE
Suzanne Haley DMD as previously presented on SleepScholar.com website January 20, 2016
Bruxism is a condition in which a person grinds or clenches his teeth. People who have bruxism may unconsciously or consciously clench their teeth together during the day or clench and grind them at night. Signs and symptoms of bruxism may include: sounds of grinding or clenching; teeth that are flat, fractured, or chipped; teeth that have abfractions present; increased tooth sensitivity; jaw or facial pain; tight and sore facial muscles; sore jaws; headaches; periodontal tissue damage; and indentations on the tongue. The cause of bruxism is unknown but is linked to such factors as stress, anxiety, fatigue, snoring, and sleep apnea. People who clench or grind their teeth during sleep are more likely to have some degree of apnea present.
Obstructive sleep apnea (OSA) is the most common form of sleep apnea. Sleep apnea occurs when the muscles in the back of the throat fail to keep the airway open despite efforts to breathe. Sleep apnea is a medical condition in which breathing is briefly and repeatedly interrupted during sleep. An apnea occurs when the muscles fail to keep the airway open and there is a physical obstruction such as the tongue, pharyngeal muscles, epiglottis, and uvula that blocks the airway. This obstruction causes the patient to stop breathing during sleep. An apnea is an event where the patient stops breathing for a minimum of 10 seconds during sleep. A hypopnea is an event where the patient has significantly reduced airflow because of a partially blocked airway for at least 10 seconds while sleeping. Patients with obstructive sleep apnea will have multiple apneas/hypopneas every night while they sleep, with the potential to severely impact their health. There are three different types of obstructive sleep apnea. These classifications depend on the number of apneas and hypopneas, divided by the number of drops in oxygen saturation. OSA deprives the body of oxygen and untreated is a potentially deadly sleep disorder. OSA can increase an individual’s risk for a heart attack, stroke, hypertension, and cardiac disease. Dentists have a unique position and can play a major role in their patient’s health because many patients are seen several times in a year.
As dentists we have familiarity and access to the oral cavity, airway, and neck. As dentists we examine and focus on the head and neck of our patients. We can view the patient’s airway, soft tissue, and dentition. We observe the tongue size, tongue shape, soft palate area, the patient’s neck size, periodontium, and the wear on the patient’s dentition. In the dental office, bruxism is seen in one out of every three patients. Two out of every five of these patients has undiagnosed or untreated obstructive sleep apnea. It is important to realize that patients who demonstrate bruxism often have obstructive sleep apnea. Sleep bruxism is considered a sleep related movement disorder. People who clench or grind their teeth during sleep are more likely to have other sleep disorders, such as snoring, pauses in breathing, and sleep apnea. Mild bruxism may not need to be treated. However, in some patients, bruxism can be frequent and severe enough to cause jaw disorders, damage to teeth, and headaches. Dentists can screen for teeth grinding and can tell if a patient is grinding their teeth at night. Bruxism can be treated with an appliance made to prevent grinding and /or clenching. Dentists can refer patients to their physicians for the diagnoses of sleep apnea and then dentists can treat sleep apnea patients with oral appliances as well.
However, because there is a link seen between grinding and sleep apnea, dentists need to play a larger role and have a relationship with a sleep physician and other medical doctors. Dentists can diagnose and provide the therapy needed for bruxism and provide the therapy for obstructive sleep apnea, once a physician diagnoses the apnea which is a medical condition requiring a medical diagnosis. Dental sleep medicine is a fast growing area of dentistry. There are approximately 40 million people in the United States with obstructive sleep apnea (OSA), with 90% of those undiagnosed. One in four patients with OSA suffer from nighttime teeth grinding. The ending of an apneic event may be accompanied by a number of mouth phenomena, such as snoring, gasps, grunts, and mainly teeth grinding. Teeth grinding occurs because of the significant attempts to open the mouth to breathe. Bruxism usually occurs after an apnea event. One of the ways the brain tries to reopen the airway, in an unconscious state, is by grinding and clenching the teeth. Teeth grinding is a major indicator that you are struggling to keep your airway open at night and might suffer from obstructive sleep apnea. When the airway collapses, breathing becomes compromised. This is where you get snoring, which is just the sound that’s made when air is getting forced through a partially obstructed airway. Once the brain senses that breathing is dangerously compromised, it exits the deepest stage of sleep to regain control of the jaw muscles and reopen the airway – to keep a person breathing and alive. These sleep apnea cycles can occur from five to up to 70 times per hour during sleep. These events prevent one from entering the deepest stages of sleep where the brain and body tissues can repair themselves from the wear and tear of the day. A dentist’s role in this process is to provide screening, therapy for bruxism, and therapy for obstructive sleep apnea when diagnosed. Dentists are not only qualified to provide the necessary dental treatment for this life threatening disorder but are uniquely in a position to screen and refer our own patients for sleep apnea diagnosis. Another screening application the dentist can provide is the Epworth Sleepiness Scale (ESS) to all patients. ESS is a scale, which measures a person’s average level of daytime sleepiness.The scale consists of eight different routine life situations. Each question is rated from zero to three, with three having the highest chance of falling asleep. If a patient scores nine or above and demonstrates excessive daytime sleepiness this needs to be discussed and researched further for explanation on why the patient is excessively sleepy. When it is determined that a patient is a grinder/clencher, snores, and has an ESS score of 9 or above, the patient is a prime candidate for a sleep test. Patients may be referred to a sleep physician, pulmonologists, or their personal primary physician for a sleep study. The home bruxism/sleep test (STATDDS Bruxism/Sleep Monitor) is typically used to diagnose bruxism and sleep apnea (Figure 1). In the dental office, dentists can administer a home test to measure the patient for bruxism and at the same time receive the apnea/hypopnea index which measures obstructive sleep apnea. The AHI can be shared with the patient’s physician. The dentist can work with the patient’s physician as coprimary healthcare providers and come up with a treatment plan together that can address the bruxism and the obstructive sleep apnea. As dentists, we only diagnose the activities occurring during sleep that are related to the clenching and grinding. Heightened bruxism events occur more frequently at the end of an apneic episode. The results of the bruxism/sleep study are sent to a certified sleep physician who gathers the information and provides a diagnosis determined by the total number of pauses that occur per hour of sleep. If the patient has only grinding/clenching issues and no apneic events or drops in the oxygen saturation then a night guard is treatment planned for the patient. Dentists should not be fabricating and placing dental appliances without objective data from a bruxism/sleep test and a proper diagnosis, to avoid creating an obstruction in the patient’s airway with the appliance for grinding/clenching (Figures 2 and 3). Moreover, if the study is returned with a diagnosis of mild or moderate obstructive sleep apnea, then a proper dental sleep appliance should be one of the recommendations for treatment. A mandibular advancement sleep appliance can be fabricated for that patient and can be titrated based on post testing with the home bruxism/sleep monitor. There are several types of sleep appliances for the treatment of obstructive sleep apnea (Figures 4 and 5). The devices move the
mandible and tongue forward allowing the airway to remain opened. There are appliances for a patient who is a bruxer and an OSA patient. There are oral appliances for an OSA only patient. Also, for severe sleep apnea sometimes a patient will wear a combination of an appliance with positive airway pressure therapy. Furthermore, for severe OSA who cannot tolerate a CPAP type device, an oral appliance is recommended as it is better for the patient to have some means of opening the airway and alleviating obstructive sleep apnea. Oral devices to treat obstructive sleep apnea must be prescribed by a physician and fabricated and fitted by a dentist. Dental oral appliances are convenient form of sleep apnea treatment. The compliance rate is higher than CPAP treatment with OSA patients. The devices offer the benefits of a significant reduction in apnea for mild to moderate OSA patients. Also, the elimination and or reduction in both grinding, clenching and snoring. Dental practices have the unique advantage of seeing their patients frequently and access to the oral cavity to identify potential sleep apnea patients.