It’s Time to Wake Up to the Sleep Dentistry Revolution

Nov 14 / Dr. Sandhya Krishan
The dental profession has been asleep at the wheel when it comes to our opportunity to help patients with their sleeping or airway problems. Despite visible symptoms in the oral cavity, this area continues to be neglected. Even if dental schools rarely emphasize airway-focused dentistry, it’s no excuse. It’s high time we awaken from our slumber, smell the coffee, and begin to address this essential issue.

Initially, my dental practice consisted mainly of restorative dentistry — “drill and fill.” However, rather than the helpful practitioners we were, patients perceived us as bearers of bad news. Finding cavities was a chore, with nary a hug in sight. Playing the good guy wasn’t easy.

Until one day, during a Continuing Education course on airway dentistry, it clicked — an exclusive “aha!” moment that transformed my approach to serving patients. This epiphany changed the trajectory of my profession forever.

To appreciate the importance of combating sleep apnea, we first need to understand it. Sleep apnea is a serious sleep disorder where one’s breathing stops for 10 seconds or more several times a night during sleep. Patients may also experience upper airway resistance syndrome (UARS), which involves partial airway blockages during sleep, leading to increased effort in breathing. During these obstructions in breathing, the brain is deprived of oxygen, leading to disrupted sleep patterns and reduced deep and REM sleep levels.

Studies have revealed that sleep apnea can lead to a multitude of problems, including mood disorders, depression, and fatigue. The risk of stroke and heart attack increases due to the body’s inability to regulate blood pressure, especially in untreated cases. Furthermore, a direct link has been identified between sleep apnea and Alzheimer’s disease. People often suffer from daytime drowsiness, leading to decreased overall quality of work performance and life. Over 100,000 vehicle accidents a year are due to sleep deprivation of all kinds.

Frequent and loud snoring is one of the most common signs of Obstructive Sleep Apnea (OSA). For those who breathe through their mouths, airway blockages may be due to swollen tonsils or tongue placement. These blockages can cause nocturnal awakenings, sometimes misconstrued as bathroom visits. Most people with OSA aren’t even aware of it unless they have a bed partner who complains about snoring. Shockingly, 80% of Americans with sleep apnea remain undiagnosed. That’s where we come in to help.


The OSA Oral Cavity Connection: What Can We Do?

Sleep-disordered breathing (SDB) can manifest itself in various oral symptoms, which dentists are well-equipped to identify. Bruxism, a common manifestation of SDB, can lead to buccal exostosis, mandibular tori, and Abfractions — all clear warning signs of potential SDB. In combination with a small jaw structure and retrognathic mandible, which can create crowded dental arches, proper tongue positioning can become restricted, resulting in a scalloped tongue. With limited space, the tongue sits low and retracts into the oropharynx, obstructing the airway. It is crucial to diagnose and treat these symptoms promptly to improve the quality of sleep and breathing.


How My Eyes Were Opened to Sleep Dentistry

My father was a structural engineer who came to Texas from India in 1968. My mother was a dentist who arrived in 1972, but her Indian degree was not recognized in Texas. Dad took three jobs to support her to go to the Georgetown University School of Dentistry and sent my sister and me to relatives in India for two years so she could concentrate on earning her new degree (after being given one year of credit for her prior degree).

I wanted to follow in my father’s footsteps in engineering, but he encouraged dentistry. He said it would make me my own boss and allow a balance between work and life. My mother was my best friend, and we planned to practice together. Sadly, she passed away just before I could start at UTHealth Houston School of Dentistry in 1996.

Inheriting her practice was a momentous occasion for me! As someone who thrives on social interaction, working with patients brought me immense joy and connection. However, I yearned for a deeper sense of fulfillment until I chanced upon a CE on sleep dentistry with no idea what to expect. The presentation left me in awe — the transformation dentists could deliver to their patients’ breathing and sleep patterns impacting their lives. It was a truly jaw-dropping (or jaw-widening) revelation! I knew at once that this was what I was meant to do.

I truly believe divine intervention altered my career’s course, even though it took me a few years to give it the focus it deserved. And now, my classmate turned partner and I treat patients at the Dental Studio of Carrollton, Texas (near Dallas), Dr. Robert Limosnero, shares in my passion for encouraging our colleagues to make this an essential part of their practices.


The MAD Solution to Sleep Apnea

In about 80% of cases where patients experience airway blockage, it’s caused by a retroglossal obstruction that can be resolved with Oral Appliance Therapy (OAT). A 3D cone beam scan is taken to identify the cause, which is often the tongue position. In the remaining cases, the blockage is located north of the maxilla and requires referral to an Ear, Nose, and Throat specialist. This type of obstruction could result from a deviated septum or chronic nasal congestion leading to enlarged turbinates, which impedes airflow and needs to be addressed to improve breathing.

I educate patients about their treatment choices, including the most commonly prescribed by doctors, the CPAP or Continuous Positive Airway Pressure. I encourage those who prefer this to continue; however, approximately 50% are non-compliant due to discomfort — so much for the “gold standard” (Long-term use of CPAP has consequences as well). Although CPAP is widely prescribed, it’s not the only option, and many doctors aren’t sufficiently familiar with oral appliance therapy (OAT) as a viable alternative. Instead, let’s work with patients to devise personalized solutions rather than forcing them into a one-size-fits-all approach preferred by some doctors.

The most common alternative is a mandibular advancement device (MAD, an FDA-approved oral appliance customized for each patient by Modern Dental Laboratory), which pulls the mandible forward relative to the maxilla to widen the airway and prevent closure.


Additional Airway Therapy 

Patients can also benefit from seeking help from a myofunctional therapist for physical therapy of the lips, tongue, and cheeks, as it helps to address how these areas impact the airway and teeth position.

Personally, I have experienced the discomforts of headaches, jaw pain, and snoring due to orthodontic treatment with headgear, but I have learned that having a forward-positioned, wider jaw can prevent these issues. I collaborate with an orthodontist (ODO) to design aligners that address specific issues, providing effective treatment for patients.

Our profession needs an honest dialogue about traditional approaches that neglect underdeveloped jaws, airways, and tongue placement. I have been warned that speaking up could mean fewer referrals, but it’s a risk worth taking.

Our patients deserve the best, so we’ll brave any criticism to embrace this new frontier of sleep dentistry because a good night’s sleep is nothing to yawn at!

About the Author

Dr. Sandhya Krishan attended the University of Houston and earned her DDS degree at the University of Texas Dental Branch in Houston. Her mother was also a dentist. Though they were never able to practice together, Dr. Sandhya’s memories of her mom are the inspiration for her own compassion and dedication to her practice.