How are Mouth Health, Brain Health, and Sleep are Connected
New year New you! Let’s Start the year with breathing!!
Breathing is the most essential element to sustain life. Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6. After 10 minutes without oxygen, brain death occurs. Brain death means there is no brain activity. A person needs life support measures like a mechanical ventilator to help them breathe and stay alive.
If you or a loved one are mouth breathing it not only affects the amount of oxygen that gets to your brain it affects your sleep as well.
Sleep quality, breathing, brain, body, and mouth health are closely related. Sleep deprivation can not only lead to brain fog but dental health issues like bleeding gums, loose teeth, gum infections, teeth grinding, and snoring. If left untreated for long, it can even lead to tooth decay and tooth loss! The reason I am talking about this is personal: It all started with a bedwetting and finger-sucking habit my daughter was dealing with. She was waking up tired, with dark circles under her eyes and having headaches.
While searching for a solution I found myofunctional therapy and it led me to the path I am on today.
Sleep-disordered breathing in children is often associated with behavioral and learning issues and is stressful for the whole family.
There is a greater need for recognition and awareness of sleep disorders and sleep-disordered breathing. Identifying sleep issues and the simple steps you can take to promote nasal breathing can make a huge difference in the prevention of Obstructive sleep apnea. (OSA)
Kids with OSA struggle to function and stay awake, leading to behavioral and learning problems, mood swings, bedwetting, and speech delays. Kids with OSA have difficulty following directions and are 5 times more likely to be diagnosed with ADHD and ADD. What is worse is 95% of children with OSA are never diagnosed!
Poor sleep can lead to a bunch of health conditions, including weight gain, brain fog, bleeding gums, and even cavities. Working with a professional can improve your airway health for better sleep. Not all dental professionals have sleep airway knowledge. The right kind of help is not easy to find.
Sleep deprivation, regardless of the cause, has been shown to cause complex oral, systemic, and cognitive health issues resulting in poor health and chronic illness.
My job as a dental hygienist isn’t just to do cleanings —it’s also to evaluate and screen patients for periodontal disease, oral habits, tongue ties, airway breathing, and other health concerns, in partnership with Dentists and Doctors, to treat those issues that help keep the airway open during sleep. As a dental hygienist, airway health and sleep are some of the many things we can evaluate and look for during routine checkups.
You might notice symptoms like snoring, teeth grinding, noisy breathing, night walking, bedwetting, and think they are normal and your child will outgrow them. The thing is these are common but they are not normal! They are symptoms of a bigger problem.
“Dental Sleep Medicine” is the term given to this area of specialty since 1991, the American Academy of Dental Sleep Medicine (AADSM) has educated dentists on the importance of treating sleep apnea, snoring, Grinding, clenching, and other sleep-disordered breathing conditions.
One area that has a direct effect on oral structures and oral health is poor sleep quality and open mouth breathing. Sleep is a fundamental process of the human body, it regulates our core biological functions. Sleep quality reflects a person’s ability to fall asleep, stay asleep, and enter into the various rejuvenating sleep cycles. A person who does not obtain quality sleep and has disrupted sleep patterns can exhibit a wide range of oral, systemic, and cognitive health problems.
Obstructive sleep apnea has historically been considered to be an adult male disease, is being recognized more often now in both women and children. Research suggests various oral malformations found in newborns and young children can manifest as obstructive sleep apnea when they become adults. Oral health professionals are in a perfect position to recognize the relationship between sleep and health, identify sleep quality concerns in relation to oral health assessments, look for tethered tissues, do sleep quality assessments, and determine the appropriate referrals for further evaluation.
Optimum quality and quantity of sleep regulate our core biological functions. Although the amount of time a person is engaged in sleep is important, reaching rem and the deep rejuvenating stages of sleep is essential for optimum health benefits. Sleep quality reflects how well a person is able to fall asleep, cycle through the various stages of sleep, and stay in those sleep stages for the full duration needed to function. Often, manifestations of poor sleep are misinterpreted as behavioral issues, cognitive dysfunction, and/or systemic health concerns, that may present differently in children and adults.
The National Sleep Foundation estimates that 50 to 70 million Americans are affected by chronic sleep disorders or sleep disruptions that can significantly affect health and safety.
The Centers for Disease Control and Prevention (CDC) has declared sleep deprivation a public health crisis. The key sleep disorders listed by the CDC include insomnia, narcolepsy, restless leg syndrome, and sleep apnea. Sleep deprivation, regardless of the cause, has been shown to cause complex oral, systemic, and cognitive health issues resulting in poor health-related quality of life and decreased work productivity.
Oral health professionals are in the optimal position to detect a sleep quality concern due to the oral appearance of individuals suffering from chronic poor sleep issues. When poor sleep is suspected, there are signs we can see early so we can refer patients to an appropriate health professional.
Sleep problems are serious with serious consequences. For our kiddos, it can affect their physical growth and development, mental IQ, problem-solving, focus, mood, and social status
The American Dental Association has adopted a formal policy statement that states dentists should include screening for sleep-related breathing disorders during all oral examinations to determine the best course of action for that patient.
The American Dental Hygienists’ Association also recognizes the dental hygienists’ ability and responsibility to identify oral and systemic health relationships and refer patients to the appropriate health professional for a patient to obtain optimal health outcomes.
Even if the quality of sleep is a concern, there is a general lack of awareness, communication, and support between medical and dental teams to provide a continuity of care for patients.
Training received by oral health professionals includes looking at medical and dental histories, identifying abnormal oral structures, detecting oral disease, identifying oral/systemic health links, and, more specifically, identifying signs and symptoms of sleep-related bruxism(teeth grinding), snoring, and obstructive sleep apnea (OSA).
Dental providers already provide many medically-related chairside screenings for patients including hypertension, diabetes, obesity, human papillomavirus, oral cancer, and oral side effects from cancer treatments, with blood pressure screening being the most prevalent screening.
Early detection of oral health and systemic health-related condition, such as a sleep disorder or poor sleep condition, has the potential to reduce comorbidities associated with poor sleep health.
Poor sleep quality can be a multifactorial situation that can affect a person’s sleep environment, physiological features related to systemic health, oral myofunctional disorders, restricted airway, and/or chemical and electrical imbalances related to melatonin or circadian rhythm. Sleep deprivation, including OSA, does not discriminate according to age, gender, or body composition. OSA is not often identified in childhood, because the severity of signs and symptoms tend to increase through developmental growth into adulthood. Research suggests oral structure formation and health concerns can put men, women, and children at risk for a poor sleep situation that needs to be identified and addressed.
While sleeping, an individual’s mind and body are performing very specific functions that are vital to the regulation, maintenance, and repair of specific body systems. Each of the three non-rapid eye movement (NREM) stages of sleep serve a specific function to quiet the body and brain, lower body temperature, and slow heart rate to prepare the body and organ systems for maintenance and repair.
The rapid eye movement (REM) stage of sleep allows the mind to transfer new memories and lessons to long-term memory, rationalize emotions, and is vital for brain repair and maturation. A quality sleep event includes five to six specific cycles of the various NREM and REM stages over a 7- to 9-hour period. Each cycle is different from the last and serves a different purpose. As the sleep event progresses, a person spends more time in REM sleep and less time in the NREM stages. Each time a person experiences sleep arousal or is pulled out of the deep stages of sleep, they are prevented from obtaining rejuvenation of the body and brain needed to achieve or maintain optimal health. Sleep arousals can be caused by poor sleep hygiene, restricted airway, systemic health issues, or cognitive health issues.
Systemic Health Concerns Related to Poor Sleep
Due to the role sleep quality has on the body and brain repair and rejuvenation many health risks can be factors that either contribute to poor sleep, are caused by poor sleep, and/or are exacerbated by poor sleep. A strong correlation between hypertension, cardiovascular disease, and stroke compared with the quality and quantity of sleep has been consistently shown in the literature. Children who have undiagnosed and untreated sleep disruptions and/or sleep disorders are also at increased risk for hypertension and Type II diabetes When an individual is not reaching the N3 stage of sleep or staying in this stage for an adequate amount of time, glucose and insulin regulation is altered. Obesity has a cyclical relationship with poor sleep quality and hormone and metabolism regulation. Overweight persons are at a higher risk for airway obstruction resulting in poor regulation of metabolic hormones. To continue the cycle of poor sleep and obesity, individuals who are sleep deprived are more likely to make unhealthy food choices and consume more calories during the day in an effort to increase energy levels. Open-mouth breathing, obesity, and poor sleep quality conditions and disorders have been correlated with a higher risk for developing gastroesophageal reflux (GERD) and other esophageal conditions. Sleep-disordered breathing and asthma have been correlated, as both are inflammatory disorders of the upper and lower airways and can contribute to respective worsening of each condition and possibly lead to OSA and the need for a c-pad machine
To make matters more complicated, many of the medications used to treat sleep-related medical conditions contribute to poor sleep due to the type of receptor antagonist effect in the brain. According to the National Sleep Foundation, medications taken to treat nasal congestion, hypertension, heart disease, thyroid disorders, birth control, breathing issues, and cognitive health concerns can contribute to difficulty with falling and/or staying asleep.
Cognitive Health Concerns Related to Poor Sleep
An individual who is unable to reach the brain repair and rejuvenation stage of sleep called REM is at risk for cognitive health issues. Individuals who are unable to reach and maintain REM sleep have been shown to be at greater risk for attention deficit disorder, bipolar disorder, depression, anxiety, emotion control, cognitive flexibility, and memory processing. Individuals suffering from post-traumatic stress disorder have been shown to have difficulty reaching and maintaining REM sleep, which in turn makes management of this disorder more difficult.
ORAL HEALTH ASSESSMENTS THAT IDENTIFY POOR SLEEP QUALITY
Multiple assessments routinely performed by oral health professionals can assist in identifying sleep quality concerns. Temporary or chronic poor sleep quality and/or quantity can be evident in a person’s initial general appearance, attitude, and physical ability. Behavioral manifestations such as irritability, impatience, yawning, falling asleep during the appointment, slow body movements, and lack of interest or focus in conversation may all be indicators a patient might be experiencing chronic sleep quality issues. Chronic poor sleep quality and/or quantity situations can affect facial feature appearance, the formation of oral structures, and the development of oral disease.
Your Health History is an important piece of the puzzle, information regarding your health, lifestyle, and cultural beliefs can help a health care provider determine the best avenues of treatment for ideal health outcomes. Learning about our patient’s lifestyle such as type of work, family life, and social life can be indicators of quality of life and sleep quality. I have had so many patients say what does that have to do with my teeth? I am just here for teeth cleaning! Oh, but it is more than just a cleaning! Our mouth is the window into the health of our bodies. We do not pay enough attention to what our mouth is telling us.
Individuals who work a rotating shift or have chronic fragmented sleep tend to have more systemic health issues and make more decision-making errors than those on the standard day shift due to sleep quality disturbances associated with working a rotating schedule.
Oral health professionals are trained and qualified to review complex medical histories. Obtaining a complete and accurate medical history includes noting any health conditions a patient might have along with prescription medications, medicinal supplements, and recreational substances they consume regularly. Health conditions such as heart disease, diabetes, mental health conditions, cognitive difficulties, and behavioral concerns need to be noted to provide a safe, comfortable, and productive oral care appointment. Medical histories used in an oral health setting should include questions surrounding sleep quality, sleep quantity, and previous diagnosis of a sleep condition such as insomnia or OSA. A patient’s dental history can also reveal a history of poor sleep due to how oral structures have formed and wear patterns on the dentition. History of orthodontics, missing teeth, clenching/grinding, open mouth breathing, and having a high caries risk can all indicate a poor sleep quality concern when paired with other aspects of the patient’s whole health and reports of poor sleep.
History of nighttime urination, waking with dry mouth, headaches, stuffy nose, or a sore throat are all red flags signaling possible airway issues. I was seeing a urologist for years. He gave me meds that caused side effects like dry mouth, dry eyes, and vaginal dryness. Very few people including me see that they may be torturing themselves because we don’t know what we don’t know. After working with a myofunctional therapist and learning about mouth taping. I no longer get up three times a night to pee, wake up coughing, and need a drink of water and I am getting uninterrupted sleep for at least six hours. I was lucky to get three consecutive hours before I learned about mouth taping. I thought it was my bladder waking me up. Turns out it was an airway problem and my mouth breathing was the culprit waking me up. If I had only known sooner my health history may have been prevented.
The extraoral examination should be performed at all preventive oral care appointments, including an examination of the head and neck for any abnormalities in shape, size, color of the skin, muscle tone, tongue assessment, and bony structure development.
Facial features that should alert a health care provider for a sleep quality concern can include flaccid skin tone, recessed chin, short upper lip, open lip posture, open bite, chronic dry lips or excessively wet lips, dried food at the corner of the mouth, long and narrow face, dark circles under the eyes and overall posture.
The intraoral examination is also performed at all preventive oral care appointments. This process includes an examination of the hard and soft tissues
Inside the mouth includes the gingiva, tongue, buccal mucosa, hard and soft palates, teeth, and oropharyngeal area. A periodontal assessment includes recording probe depths, which indicates bone loss, gingival attachment loss, and bleeding upon probing. X-rays are taken as needed to help identify oral diseases such as dental decay, compromised periodontium, and other oral issues.
Research suggests poor tongue placement leading to sleep quality concerns can be traced back to infancy and is strongly linked to an infant’s ability to nasal breathe, suck, and swallow. Open-mouth breathing and tongue placement are directly related to the formation of the maxilla, sinuses, nasal cavity, and palate. The formation of the oral structures has a direct effect on the ability to breathe, chew, and swallow properly.
Additional signs and symptoms relating to poor sleep quality may include structural malformations such as tongue-tie known as ankyloglossia, enlarged tonsils, malocclusion, and a high narrow palate. Tongue ties have been shown to be associated with a high narrow hard palate. Restricted tongue movements, abnormal formation of oral structures, and restricted airway may contribute to poor plaque control, xerostomia dry mouth or excessive saliva, open mouth posture, and tongue thrust upon swallowing. A large tongue known as Macroglossia may indicate the patient is using the tongue to protect the airway while sleeping. Missing teeth or no teeth can also cause the tongue to fall back into the airway during wakefulness and sleep states due to the lack of teeth to keep the tongue in its proper position. Lack of teeth also causes changes in the vertical dimension of the face, thereby affecting the upper airway. Enlarged tonsils that crowd into the airway can contribute to open mouth breathing, sore throats, and ultimately poor sleep quality. Other oral indicators of open mouth posture and poor sleep quality can include gingivitis, periodontal disease, xerostomia, high caries risk, poor plaque control, poor saliva control, edentulous, or missing teeth
These findings are related to improper tongue placement and the inability to close the lips properly during sleep. In addition, missing teeth may prevent the proper fitting of the continuous positive airway pressure (CPAP) mask during use.
If an obstructed airway is suspected due to large tongue and tonsil size, the Freidman Staging System, which is often used in medical settings to assess airway, is a useful tool to provide a measurable anatomic description to document obstruction. This system classifies tongue position and tonsil size according to anatomical features visualized when the mouth is open and relaxed. A resting tongue position that covers the mandibular teeth and prevents visualization of the entire oropharynx and soft palate is likely to be contributing to significant airway obstruction. Likewise, tonsil size and degree of lingual tonsil hypertrophy should be evaluated to determine the degree of airway obstruction.
Many sleep quality questionnaires are available online that have been proven valid and reliable. Researchers now know that women and children are also at risk for poor sleep quality for environmental and systemic health reasons. Also, a patient’s lifestyle, health history, and oral assessments might indicate a poor sleep condition that is not related to an obstructed airway.
As evidence continues to support the need for integrated health care, medical providers have shown an increasing willingness to collaborate with oral health professionals to enhance patient health outcomes. An overall health evaluation by a primary care provider should be undertaken to determine the patient’s general state of health before determining if sleep hygiene, systemic health, or cognitive health concern is contributing to poor sleep and then direct the patient to the proper specialist. A variety of health care providers can support patients with sleep quality concerns including ENT’s, pulmonologists, otolaryngologists, allergists, speech-language pathologists, orthodontists, oral myofunctional therapists, and dental professionals who specialize in alternative airway appliances. The American Academy of Dental Sleep Medicine (www.aadsm.org) offers a list of dental sleep medicine specialists by state.
The referral regarding sleep quality concerns should include the sleep quality assessment tool, patient report of sleep experience, oral assessment risk factors, and documented charting of anatomical considerations including oral features of the tongue, palate, tonsils, and facial profile.
Several treatment options are available for restricted airway concerns depending on the type of restriction, age, and overall health of the individual. The most common treatment for chronically enlarged tonsils is an adenotonsillectomy or removal of the tonsils. A surgical procedure alone does not necessarily restore normal nasal breathing during sleep.
However, in some cases, tonsil removal along with oral myofunctional therapy has been shown to produce more positive results in achieving improved sleep quality. Oral myofunctional therapy, which consists of specific exercises to strengthen and retrain the tongue, soft palate, and pharyngeal walls, may be an effective adjunct in OSA therapy and was shown to reduce the apnea-hypopnea index by 30%–40% in adults.
Exercises to strengthen the muscles of the face and improve tongue placement in the oral cavity can contribute to a decrease in snoring, improvement in daytime sleepiness, improvement in PSG polysomnography sleep test results, and improved blood oxygen saturation.
Treatment of OSA often includes the use of a CPAP device, which forces air through a face mask or nasal cannula worn on the patient’s face to keep the airway open during sleep. This is the most effective method for preventing apneic events during sleep, but the compliance rate for continuous use of a CPAP is low and the mouth breathing issue has most likely not been addressed.
Improved quality of life and health was reported in several studies in conjunction with long-term use of a CPAP machine in those with moderate to severe OSA. For individuals diagnosed with mild to moderate OSA, a mandibular advancement device, made by a dentist, was found to have similar effects as a CPAP device, possibly due to the higher compliance rate.
Other treatment options for patients with OSA might include surgical procedures such as a frenectomy, orthodontia, and adenotonsillectomy.
Patients should be made aware that multiple options are available for treating obstructive airway, and more than one treatment modality may be indicated based on their severity of OSA, head and neck anatomy, and ability to tolerate various interventions.
At each continuing care appointment, the oral health professional should document all concerns and actions taken to remedy sleep quality concerns. Further sleep quality care will be determined along with the primary care provider, oral health provider, and patient once newly performed oral health assessments have been performed upon the implementation of sleep quality interventions.
Sleep deprivation has become a national health crisis affecting individual health, safety, and quality of life. There are many different reasons for sleep deprivation including poor sleep hygiene, systemic health issues, and sleep disorders. Most people who suffer from daytime sleepiness are not aware that poor sleep is affecting long-term and short-term health.
The training, expertise, and unique patient interactions between the patient and oral health care practitioners lead to systemic health findings during oral health assessments. Sleep quality is an important component of oral health and systemic health, which requires integrated health care teams.
Spread the word… Join the movement…optimize your health and the health of your family.
Healthy sleep is a game changer—so don’t ignore this one!
- Koo DL, Nam H, Thomas RJ, Yun CH. Sleep Disturbances as a Risk Factor for Stroke. J Stroke. 2018;20(1):12–32. [PMC free article] [PubMed] [Google Scholar]
- Carley DW, Farabi SS. Physiology of Sleep. Diabetes Spectr. 2016;29(1):5–9. [PMC free article] [PubMed] [Google Scholar]