A VICIOUS CYCLE: Sleep Apnea, Sleepiness, Anxiety, Caffeine and Bruxism

We know there is a correlation between bruxism and sleep apnea, but how does the one contribute to the other?

It has been observed that a third of bruxism patients also suffer from sleep disorders like sleep apnea, restless legs syndrome, etc. Bruxism may be the effect or the cause of many types of sleep disorders including obstructive sleep apnea, snoring, daytime lethargy.

The effects of stress, anxiety and caffeine ingestion come into play here. Studies link high anxiety levels to bruxism, and the symptoms of sleep apnea itself may cause anxiety. Additionally, the daytime sleepiness caused by apnea may lead to high levels of caffeine consumption which, in turn, is linked to a high risk of bruxism. This is the vicious cycle.

The relationship between sleep bruxism and sleep apnea can be attributed to an arousal response. When an apnea event ends, various oral phenomena may occur: snoring, gasping, choking, grunting and teeth grinding. Immediately after the apnea episode, a physiological compensation occurs. The jaw will open and close, thus dilating the upper airway in order to facilitate normal breathing.  The patient then pushes the tongue forward to move away from the air tract and forces it against the teeth.

Research has shown that increase of teeth grinding is directly proportional to the increase of frequency of apnea episodes.The results of these studies suggest that when sleep bruxism is related to apnea/hypopneas, the successful treatment of these breathing abnormalities may eliminate bruxism during sleep.

A VICIOUS CYCLE: Sleep Apnea, Sleepiness, Anxiety, Caffeine and Bruxism

What is the Connection between Bruxism and Sleep Apnea?

We know there is a correlation between bruxism and sleep apnea. But how does the one contribute to the other? 

Systemic interdependence is demonstrated by the comorbidities of sleep apnea, 
which include acid reflux, high blood pressure and sleep bruxism.

Definitions
Nocturnal Bruxism

Nocturnal bruxism is characterized by nighttime teeth grinding, gnashing 
or clenching. 
People with this condition unconsciously grind their teeth during sleep. 
Many are unaware of their problem. 
Bruxism can happen to any adult or child at any point in their lifetime. 
Some identified causes are  a high level of stress or anxiety, excessive 
consumption of alcohol; caffeine; use of some types of antidepressants; 
smoking; abnormality in teeth alignment; effect of a condition like Parkinson’s, 
or it could be sourced back to earache or pain in another part of the body. 
Sleep disorders like sleep apnea and restless legs syndrome are found  to be 
concurrent during teeth grinding. 

The clinical manifestations of bruxism are attrition or fractures of the incisal 
edges of anterior teeth, wear on the occlusal surfaces of posterior teeth and 
abfractions occuring on the facial sufaces at the cemento-enamel junction (CEJ).

Sleep Apnea
Sleep apnea is a sleep disorder with potentially dangerous 
complications. It involves repeated stops and starts in breathing. 
People with this condition usually snore loudly during sleep and feel 
tired when they awake.

There are two main types of sleep apnea: obstructive sleep apnea and 
central sleep apnea. OSA, the more common form, occurs when throat 
muscles relax during sleep. Central Sleep Apnea involves problems with 
brain signals that control breathing. Complex sleep apnea, a less common
form, combines the two.

Sleep apnea results from a narrow or blocked airway. The lapses in
 breath arouse the sleeper and reopen the airway. The process may repeat 
several times throughout the night even though most people do not 
remember awakening. Apnea events may occur many times during a night. 
The risk of OSA.may be increased by obesity, high blood pressure, 
medications, alcohol consumption and smoking.

Causal relationships   
It has been observed that a third of bruxism patients also suffer from 
sleep disorders like sleep apnea, restless legs syndrome, etc.
 Bruxism may be the effect or the cause of many types of sleep disorders 
including obstructive sleep apnea, snoring, daytime lethargy. 
The effects of stress, anxiety and caffeine ingestion are in play. 
Studies link high anxiety levels to bruxism, and the symptoms of sleep apnea 
itself may cause anxiety. Additionally, the daytime sleepiness caused by apnea 
may lead to high levels of caffeine consumption which, in turn, is linked to
 a high risk of bruxism. This is the vicious cycle.

Treatment Options

When bruxism is associated with OSA, certain therapies may treat both problems.
CPAP (Continuous positive airway pressure) and OAT (Oral Appliance Therapy) 
will keep a sleeper’s airway open to allow for normal breathing. 
It has also been shown to decrease sleep bruxism.  
Mandibular Advancement Appliances (MMAs) have been seen to reduce events 
of bruxism by as much as 50 to 83%.  

Studies have reported that sleep bruxism rarely occurs in isolation. 
In a study in Israel of sleep bruxism and risk factors in the general population, 
it was found that among the associated sleep symptoms and disorders, 
obstructive sleep apnea (OSA) was the highest risk factor for tooth grinding 
during sleep.  Two polysomnographic (PSG) recordings were carried out. The 
first showed 67 events of sounded tooth grinding, most of them appearing
as an arousal response at the end of apnea/hypopnea events in both the 
supine and lateral postures. The results of this study suggest that when 
sleep bruxism is related to apnea/hypopneas, the successful treatment of these 
breathing abnormalities may eliminate bruxism during sleep.

 

 

 

Sleep apnea and sleep bruxism: how it all happens
Most of the sleep bruxism events happen when a subject is lying on his or her back.
 This makes us believe that sleep bruxism could happen because of 
narrowing of airway or due to rise in the resistance from airways. 
Immediately after the apnea episode, when the ventilation process resumes, 
activation of the process of jaw-opening and closing begins which in 
turn dilates the upper airway and reduces the resistance in order to ease normal 
breathing.  The patient tries to force the tongue to move away from the air tract and 
forces it against the teeth. 

In a study on nighttime bruxism in patients who are affected by sleep apnea as 
well, it was found that there was a marked decrease of apnea/hypopnea 
episodes as well as events of night bruxism were completely eliminated. 
Therefore, it can be concluded that if sleep bruxism is caused by sleep 
apnea then correcting the breathing irregularities can significantly 
improve or even eliminate sleep bruxism. 

 

 

 

 

Conclusion 

 

Research has revealed that increase of teeth grinding is directly 
proportional to the increase of frequency of apnea episodes. Since the 
link between arousals and bruxism during sleep is already 
established, it is fair to say that increase of nighttime bruxism is 
directly linked to arousals caused by sleep apnea. 
When an apnea event ends, various oral phenomena may occur:
snoring, gasping, choking, grunting and teeth grinding. 

 

 

• Resources & References

  • http://www.mayoclinic.com/health/sleep-apnea/DS00148
    • http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm
    • http://www.helpguide.org/life/sleep_apnea.htm
    • http://www.sleepapnea.org/learn/sleep-apnea.html
    • http://www.usatoday.com/news/health/2008-08-01-sleep-apnea_N.htm
    • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147220/
    • http://www.sleepfoundation.org/article/sleep-related-problems/obstructive-sleep-apnea-and-sleep
    • http://www.aafp.org/afp/2004/0301/p1147.html
    • http://sleepapnea.org/diagnosis-and-treatment/childrens-sleep-apnea.html
    • http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/causes.html
    • http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001814/
    • Sleep Disorders Unit, Loewenstein Hospital-Rehabilitation Center, Raanana, Israel.

 

 

 

 

 

WHAT IS MISSING IN YOUR COMPREHENSIVE DENTAL EXAM?

A truly professional comprehensive dental exam examination (D0150 or D0180) should include much more than what the CDT codes delineate.

What is essential?
Beyond the obvious FMX, charting of existing and needed dental and periodontal conditions, and an oral cancer screening,there are many other evaluations which are directly related to our services and are within our range of authority and responsibility. 
The Comprehensive Exam should also include measurement of vitals such as blood pressure, etc., sleep dysfunction screening such as the Epworth Sleepiness Scale, and a careful discussion of any notable items (alerts) in the patient’s med history. These things don’t need to be spelled out in the CDT code. They come with our desire to do what we know is right. If I were still practicing today I would certainly perform these and a nutritional analysis.

  TMJ exam, facial muscle palpation,Mallampati classification  (correlates tongue size to pharyngeal size) and an oxygen saturation test will provide critical information.  Any dentist/hygienist/team will chose how extensive they wish their dental exams to be and what should be included.

Would we be “spending too much time” in a dental exam visit?

Not if we care about our patient’s total well being, our conscience, and our dental license.

And is this “nearly always accepted by patients with huge value and appreciation”? YES, it is, where the dental team shows their patients how much passion, care and skill they have. I see it in many dental offices. The really successful ones.

Do you want to do more?
Here’s your opportunity to increase your service to your community, to create your “niche”, and  to stand out in your community as a complete care-giver.
It is reported that 34% of the population has SA symptoms. One of the next three patients that walk thru your doors is a Sleep Apnea victim. Are you able to help them?
Does your New Patient Exam include a screening for Sleep Apnea?

Interested? Then check this out: http://sleepgroupsolutions.com/2.0/