Early detection and intervention for sleep apnea through dental screenings

Obstructive sleep apnea (OSA) is more common that many people realize, with the American Academy of Sleep Medicine estimating that about 23 million people in the US remain undiagnosed.¹ As dental hygiene students, we’ve noticed how often sleep-related concerns connect to oral health.

Since many patients see their dental team more regularly than their primary care providers, dental professionals are in a great position to recognize signs that may point to OSA. In our literature review, we focused on one main question: how can early detection of sleep apnea be achieved in dental settings?

What is obstructive sleep apnea?

OSA is the most common sleep-related breathing disorder. When the throat muscles relax too much during sleep, they block the airway, which disrupts airflow and lowers oxygen levels.² This can lead to restless sleep and symptoms such as daytime tiredness, loud snoring, fatigue, waking up, gasping, or choking.^3,4 A sleep study is conducted to make a diagnosis, and the Apnea-Hypopnea Index (AHI) measures how many breathing interruptions occur per hour to determine severity.⁴

Early diagnosis not only relieves undesirable symptoms, but it can also prevent systemic complications. OSA is found to be linked to diabetes, cardiovascular disease, and stroke. It also has economic consequences. Untreated sleep apnea has been seen to contribute to workplace and motor vehicle accidents and increases in health-care utilization.1 Dental professionals are in a great position to intervene before OSA-related issues escalate.

What the literature says about OSA

Our literature review includes age-matched studies, case-control studies, and systematic reviews. The evidence shows strong correlations between OSA and several anatomical and intraoral features.^2-7

An age-matched study comparing patients with and without OSA found several anatomical features significantly associated with OSA. One of the strongest predictors is a large neck circumference (≥16 inches), as excess adipose tissue in the neck contributes to upper airway obstruction during sleep.^3,4,7 The study also highlighted a Mallampati classification of 4, where only the hard palate is visible when the patient opens their mouth and protrudes their tongue. This limited visibility indicates a restricted oropharyngeal space and higher OSA risk.^4,7

During routine intra/extraoral exams, dental professionals may encounter patients with a low-lying, broad tongue, which is a feature of macroglossia, which can further obstruct the airway.⁷ Narrow palatal width and narrow lateral pharyngeal walls are also noted as contributing factors, which reduce the size of the oropharyngeal airway.^4,7

Individuals with large mandibular tori greater than 2 cm demonstrated an increased risk for OSA.^4,7 Class 2 malocclusion is also associated with OSA as it can lead to the posterior displacement of oropharyngeal soft tissues during sleep.^4,5 We also identified intraoral conditions commonly associated with OSA, including mouth breathing and increased dry mouth, which lead to an elevated caries risk due to reduced salivary flow and acidic oral conditions.^2,6

Bruxism may serve as a subconscious effort to reopen the airway during sleep, causing tooth wear and TMJ issues.² Periodontal disease is more common in OSA patients, likely due to systemic inflammation and impaired immune response.^2,5 A case-control study found elevated inflammatory markers in OSA patients, supporting the idea that chronic low oxygen levels and poor sleep quality can worsen oral and systemic inflammation.⁵

OSA screening in the dental office

Knowing how signs of OSA can present in the mouth, what would screening for OSA look like in a dental practice? Dental professionals already gather much of the information needed for an OSA screening during routine visits. Here’s how it can be done:

Identify risk factors in your patient: Factors that raise the risk for OSA are age, male gender, obesity, smoking, alcohol use, and systemic diseases such as hypertension and diabetes.²

Conduct intra/extraoral exams: Look for anatomical features such as macroglossia, narrow palatal width, narrow pharyngeal walls, Mallampati class 4, large neck circumference, mandibular tori above 2 cm, and class II malocclusion. These are not diagnostic criteria but have been shown to have a higher prevalence in patients with OSA.^3,4,7

Ask your patient questions: Asking simple questions about snoring, fatigue, sleep quality, grinding, mouth breathing, and dry mouth may help identify patients at risk.⁴

Offer patient education: Explain to patients the potential risks and benefits of getting tested for OSA. Discuss referring them to a sleep specialist for a definitive diagnosis through a sleep study.²

What we learned about OSA and why it matters

We saw how common OSA is through our research and how closely it is connected to oral and systemic health. Because of the intraoral associations and connections there are to OSA, dental professionals are in a great position to notice signs early. By adding screening protocols and working closely with other providers, we can help patients get diagnosed sooner, start treatment earlier, and ultimately improve their quality of life.

We believe OSA screening should be part of dental hygiene and dental school education so that future providers feel competent in identifying and referring patients who are at risk. For dental hygienists already in practice, continuing education courses can help improve awareness about OSA.

We also found there is a need for additional research, especially in making more standardized tools, measuring how effective dental referrals are, and deepening the understanding of how OSA and oral health connect. By taking these steps, the dental community can make a difference in addressing one of the most underdiagnosed yet impactful conditions affecting patients today.

References

1. Economic burden of undiagnosed sleep apnea in U.S. is nearly $150B. American Academy of Sleep Medicine. November 8, 2017. https://aasm.org/economic-burden-of-undiagnosed-sleep-apnea-in-u-s-is-nearly-150b-per-year/

2. Maniaci A, Lavalle S, Anzalone R, et al. Oral health implications of obstructive sleep apnea: a literature review. Biomed. 2024;12(7):1382. doi:10.3390/biomedicines12071382

3. An SL, Ranson C. Obstructive sleep apnea for the dental hygienist: overview and parameters for interprofessional practice. Canad J Dent Hyg. 2011;45(4):225-238. https://api.semanticscholar.org/CorpusID:210875389

4. Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea? The rational clinical examination systematic review. JAMA. 2013;310(7):731-741. doi:10.1001/jama.2013.276185

5. Gamsiz-Isik H, Kiyan E, Bingol Z, Baser U, Ademoglu E, Yalcin F. Does obstructive sleep apnea increase the risk for periodontal disease? A case-control study. J Periodont. 2017;88(5):443-449. doi:10.1902/jop.2016.160365

6. Pico-Orozco J, Carrasco-Llatas M, Silvestre FJ, Silvestre-Rangil J. Xerostomia in patients with sleep apnea-hypopnea syndrome: a prospective case-control study. C Clin Experiment Dent. 2020;12(8):e708-e712. doi:10.4317/jced.56593

7. Ruangsri S, Jorns TP, Puasiri S, Luecha T, Chaithap C, Sawanyawisuth K. Which oropharyngeal factors are significant risk factors for obstructive sleep apnea? An age-matched study and dentist perspectives. Nat Sci Sleep. 2016;2016(8):215-219. doi:10.2147/NSS.S96450