Sleep issues often leave oral clues
by KINDRA O'RIELLEY, RDH, BSDH
The technology that our wonderful occupation provides tells us so much about the guests sitting in our chairs. We are now able to help those in need in ways we never thought possible! However, have you ever thought about what is sitting directly in front of you that you stare into with every patient? You don't necessarily need technology to be able to see what's in the patients' mouths!
This could be the key to one's overall well-being! Are you ready to wake up to what your patients' mouths are telling and showing you? It could save their lives, get them out of pain, and make you more productive and profitable!
Consider reading:Listen to your dental patients to learn more about sleep disorders
Consider reading:Seeing the light
Consider reading:TMJ assessment
When your guests come to see you as a hygienist, they expect a "cleaning." It is our professional responsibility to deliver the best care to each and every patient.
Do you do this? Care starts the moment the patient fills out the paperwork. It is imperative that dental professionals take the time to look at the health history. We are treating human beings, not a tooth or a mouth! We should not be interested in the mouth only! We need to understand what is going on systemically with our guests, searching for the clues on why we see what we do in their mouths. Often, dental visits occur more often than visits to other health-care practitioners. There is a chance that we can be clued in and recognize possible systemic issues that the patient is unaware of — all by taking note of what we see. What if you could add years to their lives? By identifying what is potentially going on with their health, we can use that information to connect the dots with what is occurring within their mouths.
Daily, the media bombards us with reports that more individuals are being diagnosed with detrimental health ailments. Our guests often arrive in pain and with headaches. Some are so sleep deprived they fall asleep in the dental chair. Obstructive sleep apnea and temporomandibular joint disorders are two of the hottest topics in dentistry today.
Let's wake up to what our patients' mouths are telling us and help our patients in ways that both they and we as dental professionals never saw coming.
As mentioned above, this starts with the medical health history. When you see headaches, high blood pressure, acid reflux, heart attacks, depression, and stroke, what do you think? Do you ask yourself how you can help? Do you think that you should possibly dig deeper into their health history? Absolutely! Our guests don't think that we as dental professionals need to know everything about their health history. Do your diligence and ask questions to get them to open up to you. A patient could be taking medication for depression and not think that it is imperative for you to know, so they don't disclose it. However, depression can go alongside with obstructive sleep apnea and TMD. Knowing your patient has depression can be a red flag suggesting that maybe you should dig deeper to see if the patient is potentially in pain due to a temporomandibular disorder or a potential sleep issue they didn't know they had. The health history can signal many red flags if the form is created properly, and if it is answered honestly.
On a health history form, it is OK to ask if the patient experiences jaw pain, headaches, neck aches, dizziness, ear congestion, clenching, and grinding. These are all issues that will help lead to conversations about TMD. How about tossing and turning at night, snoring, waking up not feeling well rested, acid reflux, and "morning" headaches? These conditions can all point to obstructive sleep apnea.
We need to find a way for the patient to admit these problems first, and sometimes the best way is through the medical health history. Once this is admitted, it is our turn to shine by educating (vs. selling) the patient on the potential issue at hand. The moment the patient follows up with a question, you have received an open invitation to provide more information. They are then sold! They will ask, "What do I do?" Treatment options in the dental setting can then be explained.
The intraoral and extraoral exams can unearth links to obstructive sleep apnea or TMD. The majority of your patients who have one of these issues will also have the other.
What makes you believe that an individual could be experiencing TMD? Usually, signs of clenching and grinding, correct? Dental professionals know tooth structures are worn down as a result of clenching and grinding. The patient loses vertical dimension or height to their teeth and jaw position. This loss in height will put the mandible in a more retrognathic position.
A few things will happen when this occurs. First, this can cause the condyles of the mandible to press into the temporal fossa in a position that was not meant to be. This can pinch delicate nerves and blood vessels that innervate the muscles of mastication and stomatognathic system, causing extreme pain. This can also cause the delicate disk to become displaced.
Secondly, when the mandible is pushed back, the tongue, fatty tissue in the neck, and muscles will also be displaced backwards. What does this distalized position of the mandible cause? It causes all of the above to be pressed into the pharyngeal airway.
When patients sleep on their backs — which happens to be the exact position used in operatory chairs — gravity pulls these tissues into the airway even more so. This can make it complicated for a patient to receive the correct amount of oxygen. These patients make it hard to suction since their tongue always pushes it out of the way. They are also the patients who fog your mouth mirror. Did you know that as an individual has an apneic episode (holding one's breathe for 10 seconds or longer), he or she will brux the mandible forward in an attempt to open the airway?
This poses the question: Which occurred first, the height of the teeth being worn down from a TMD issue and the jaw becomes displaced distally? Or, is it an individual not being able to breathe during sleep and bruxing to open the airway, which is causing wear on the teeth? Clinicians start the process of discovering the correct answer by asking the correct questions to patients. You can begin to educate them on a health ailment they may never known about otherwise. If you help them identify the ailment, you could potentially add years to their lives, save their lives, or get them out of pain.
Patients get tired of hearing, "You clench and grind your teeth." They've heard it from every dental professional they've seen. If they do it at night, they are not aware of it. They mentally prepare themselves to hear you say they need a night guard. "They are going to try to sell me on that big bulky thing that I know I can't wear, that my wife bought from here two years ago and she doesn't wear!"
Ask instead, "Has anyone ever asked you if you clench or grind?" You know they will say yes. However, don't respond. Your goal is to ask them enough questions, prompting them to inquire, "Why are you asking these questions?" This is when they are interested and ready to be educated.
Discuss the tori you see. I know instantly when I'm taking bitewings if there is an issue. I see the mandibular tori that are present. I will red flag them in my mind. When I later explain that I'm going to do an intraoral cancer screening and that I'm looking for any unusual lumps or bumps, then I bring the mandibular tori up. Patients don't like to hear that they have "lumps and bumps" in their mouths that are not normal! You assure them that they are not normal, that they are not a tumor or cancer, but that most people don't have them. Show them to the patient and point out how one is typically larger than the other.
Continue to explain that these are typically an indication of clenching and grinding. This, in combination with the wear, is probably why past dental professionals have thought the patient clenches or grinds. Let the patient know that this is why one is larger than the other. The side that has the larger tori in the mouth is probably more out of balance and gets the majority of the pressure as clenching or grinding are occurring. Explain how tori are related to clenching and grinding. It is a protective measure of the body to keep the underlying root structure safe when excessive pressures are put onto the teeth. The pressures could be malocclusion, cross-bite, clenching, and/or grinding.
It is our job to figure out what causes it. Take an intraoral picture and explain that you will monitor the size at each appointment. For if they get larger, then we know it is something occurring currently. Again, these tori could be occurring from clenching and grinding. Is the patient doing it subconsciously during the day when stressed and causing TMJ disorders, or is it at night in an attempt to open the airway to breathe?
As you discuss this possibility of nighttime bruxing, start asking them questions about their sleep. Don't respond when they answer. Let them inquire why you are asking questions. Ask them, "Do you snore?" Snoring is the vibration of air trying to get past the tongue and the soft palate. The tongue falls to the back of the throat and the soft palate collapses, and the two will touch in the oral airway.
Ask if they toss and turn in their sleep? Again this is a protective measure that the body will use when an apneic episode occurs to wake the patient in an attempt to breathe. The body will awaken to toss and turn so that the patient is aroused enough to get oxygen once again and go to a better position to allow them to breathe.
Are they well rested in the morning when they awaken or do they feel as though they need to go back to bed? If patients are holding their breath for 10 seconds or longer up to 10 times an hour (definition of obstructive sleep apnea), the heart isn't receiving the oxygen rich blood that it needs. This can cause high blood pressure, strokes, and heart attacks — more of the red flags contained on the health history.
If the heart is constantly getting worn out, the individual isn't breathing, and they are constantly tossing and turning; they may be sleeping, but the body and mind are not getting rest. This will lead to an exhausted individual left with no energy throughout the day. They no longer exercise due to the lack of stamina and begin to snack on high fat and sugary foods to get energy, and then the weight gain begins. Do you see this vicious cycle?
How about acid erosion on the teeth? Do you still assume that the problem is based on diet? It could be, but acid reflux may make more sense? This is why you will typically only see it on the mandibular teeth and on multiple teeth. As the individual lies in bed on their back, and the body works overtime for the heart, the extra force on the abdomen will cause acids to creep up into the esophagus, leaving the patient with a dry, itchy, and burning throat in the morning. Little "pools" or "craters" are created on the occlusal surfaces from this acid. Start discussing this with patients.
Lack of sleep and constant pain can lead to depression. There are stages of sleep that if we don't enter into long enough or if we don't get into the stage enough times throughout the night (because we are constantly being aroused from them), memory loss and lack of hormone regulation can occur. The lack of particular hormones can cause sexual dysfunction in adults and even stunted growth in children. This can also lead to nighttime polyuria. This polyuria will cause children to wet the bed and adults will get up frequently for restroom breaks in the middle of the night, causing even more fatigue in the mornings. These are more questions to ask your patients! Don't forget to ask parents of children. They are surprised when you suspect that the child wets the bed, when they never even mentioned it to you!
How do the tissues of the oral cavity appear? Are they dry and inflamed? Dry mouth can be a side effect of medications, but what if it is because the patient breathes through their mouth all night long? Are they a mouth breather during the day? We all know that dry tissues become inflamed. You will start to see enlarged tonsils. Enlarged tonsils are blocking the airway. People grow used to the way things are and don't recognize that it is not normal, including breathing.
Many patients will explain that the tonsils are enlarged due to allergies and drainage. This is fine, but ask them how many months out of the year that they are bothered by allergies. When they state seven to nine months, then this is not OK. Seven to nine months out of the year with the oral airway being blocked by enlarged tonsils is not healthy!
Finally, examine the tongue. When viewing the tongue, you will notice some tongues have tooth impressions on the side of the tongue or on the surface. This is called scalloped and corrugated tongue. This will occur when the patient again, subconsciously places the tongue between the teeth for one of two reasons. The first reason is to open the airway. By placing the tongue between the teeth the mandible will have vertical height added back to the oral cavity. This will bring the jaw down and forward, pulling the muscle and fatty tissues forward, including the tongue, making the oral and pharyngeal airways larger. Patients do these protective mechanisms during the day as well.
Another reason an individual will have the markings on their tongue is because they place their tongue between their teeth to act as a brace. This will put height back between the maxillary and mandibular teeth that have been worn down over time. This will also stretch overworked muscles of mastication and give relief. When teeth are worn down, these muscles have to overwork to hold the jaw in its new "collapsed" position. The muscles of mastication become sore when they are overworked and spasm. The spasms typically lead to a headache, eyeball pressure, or migraines. The body gives up and needs relief; therefore it will subconsciously place the tongue between the teeth to stretch these muscles.
It is so exhilarating to get the patient to engage in a new conversation in the dental chair. Familiarize yourself with what obstructive sleep apnea is and how the dental professional can help. Even if your office doesn't treat obstructive sleep apnea, the identification of a sleep issue can lead to a timely referral before a stroke or worse occurs. We can assume that there is obstructive sleep apnea, but without a positive sleep study you cannot diagnose it.
By identifying signs of TMD, we will see several of the same signs for obstructive sleep apnea. Are the signs of TMD from an individual that currently does have obstructive sleep apnea or possibly did in the past?
Start planting the seeds in your patients' minds. They may not move forward instantly, but they will begin to recognize the issues that you point out to them, and this will lead them to understand that there is a problem requiring them to seek help. I encourage you to start with all the patients you have in bulky soft night guards. They are wearing them to protect the teeth from clenching and grinding. Are you putting a Band-Aid over a larger issue? Are you taking up more space with a bulky appliance that the tongue needs? Possibly even pushing the tongue back into the oral airway, causing an even larger issue? Challenge yourself and your doctor to begin looking past the tooth and mouth and start to treat the human being in your dental chair the way you would want to be treated!! RDH
Kindra O'Rielley, RDH, graduated from The Ohio State University. She is the owner of Assist 4 Dentist Consulting/Lecturing Company and the Assist To Succeed DentalAssisting School in Columbus, Ohio. Kindra can be contacted at [email protected], or visit www.assist4dentist.com and www.assisttosucceedofcolumbus.com.
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