When it comes to treating sleep-related issues like snoring or apnea, you’d be forgiven if the first medical professional that sprang to mind wasn’t your dentist. But as the study of these disorders expands, the person who’s in charge of cleaning and maintaining your teeth can also be the one to help with problems that adversely affect sleep.
Sleep dentistry, commonly (and mistakenly) conflated with dentistry that uses sedation, focuses on relieving patients of sleep-related breathing disorder symptoms. Poor sleep or lack of sleep can lead to a host of health problems, and it can also be dangerous. According to AAA, 9.5 percent of all automobile crashes and 10.8 percent of crashes that resulted in significant property damage involved drowsiness.
Wilmington dentist Dr. Andrew Swiatowicz knows this from personal experience. He suffered from sleep apnea for years before getting a diagnosis and treatment. He’d always been a snorer, but as an adolescent, he often woke six or seven times during the night from his sleep apnea, which causes breathing to stop and restart as throat muscles relax. He suspects that as an adult, his poor sleep put him in mortal danger.
“I was in a four-car accident one day on the way to work,” Swiatowicz says. “If I had treated my sleep apnea before then, would I have been the tail end of that accident?”
Swiatowicz’s situation improved when he underwent a tonsillectomy in his teenage years. Now, however, he also wears a dental appliance to help him sleep restfully—and he’s devoted his career in dentistry to helping others with the same problem. He also teaches fellow professionals about sleep dentistry.
“While it’s not a recognized specialty, there’s a whole branch on how dentistry can manage breathing,” he says.
Though sleep science is relatively new, dentists have taken up a role as part of multidisciplinary care when it comes to helping patients get a full night of rest. Dentists can’t diagnose a patient with a sleep disorder or perform a sleep test, but they can provide remedies for problems that interrupt sleep, both for patients and their partners. They can also begin the conversation and guide clients to other medical professionals for further help.
Among the issues sleep dentistry can directly address is snoring. The noisy nighttime snorting, gurgling and rumbling has a simple physiological cause. During a deep sleep, jaw muscles relax. If the muscles relax enough, the jaw will fall back, or become slack, causing snoring. During the night, the neck muscles may also relax, causing the snoring to worsen. Grinding and/or clenching may result naturally to prompt the jaw muscles to tighten back up during sleep and reopen the airway, potentially damaging teeth in the process.
“While it’s not a recognized specialty, there’s a whole branch on how dentistry can manage breathing.” —Dr. Andrew Swiatowicz, Delaware Dental Sleep Medicine
A retainer-like dental appliance that clips to the teeth for security will hold the jaw forward so it cannot fall back, keeping the airway open for a good night’s rest. The device, crafted individually based on the shapes and needs of each patient’s mouth, will not hurt teeth. It could, however, help prevent the clenching or grinding that happens while also maintaining an open airway overnight.
“We do a ton of appliances every year,” says Dr. Ryan Robinson of the Pain and Sleep Therapy Center in Wilmington. “Oral appliances for the treatment of a sleep-related breathing disorder have a variety of names. Basically, each is a custom-made, laboratory-fabricated prothesis or appliance, if you will, that is made custom for each patient to maximize the room in the mouth for proper sleep.”
All told, there are more than 150 FDA-approved dental appliances used in sleep dentistry.
“Every dentist has their preferred appliance,” Robinson says. “I use about five or six regularly, and have made a ton of them over the years. But I really stick to the five or six that are most beneficial to me.”
Some have bars on the side, while others have chains or loose bands on the side, he explains. But he emphasized they all do the same thing—the set of retainers that go on both the top and bottom jaws pull the mouth forward to allow the patient to breath on their own while sleeping. Orthodontic procedures designed to widen the jaw are an option for some patients.
“It all depends on the needs of the patient,” he says. “Do they grind their jaws at nighttime? Do they clench down? Are their jaws narrow? Are they going to wear it for the next 30 years or do we have to make one temporarily before they have jaw surgery?”
Some sleep dentistry devices can be crafted during dental appointments using a heated acrylic material. Robinson emphasizes that appliances created for long-term situations, though, should be made in a laboratory.
The appliances are “pretty easy to maintain,” says Robinson. “Think of it like your retainer that you got from your orthodontist. You’re only wearing it for when you sleep. So, when you get up, you take it out. You would dip it in the cleaning agent once a week or so, depending on how gunky they get.”
Dentists will refer patients to their primary care physician for issues beyond their scope. Next, these physicians may prescribe a variety of sleep studies based on the needs of the patient, which could include a visit with a cardiologist or pulmonologist.
One of the most prevalent sleep disorders is obstructive sleep apnea (OSA), which affects some 23.5 million people in the U.S., according to the American Academy of Sleep Medicine. The disorder occurs when throat muscles relax enough to block a person’s airway while they sleep, causing breathing to stop or significantly decrease for seconds at a time. Symptoms can include daytime drowsiness, shortness of breath, irritability, lack of concentration or memory loss, and teeth grinding.
Sleep studies, whether done in office or in home, indicate the severity of the patient’s sleep apnea. For example, mild sleep apnea is characterized by five to 15 pauses in a patient’s breathing per hour while sleeping. Moderate sleep apnea involves 15 to 30 pauses per hour, while a patient with severe sleep apnea will have 30 or more pauses in their breathing per hour.
“There’s an increased risk of stroke, heart attack, diabetes, depression, cancer and a six- to sevenfold increase in mortality in untreated sleep apnea,” Swiatowicz says. For children, OSA can lead to learning disabilities or growth or hormone problems, according to the Nemours Foundation.
“This stuff was really just found out about in the 1980s. We really don’t have long-term data like with cardiovascular disease or other things we’ve known about for a long time. About 80 to 90 percent of people walking around with this condition don’t even know about it.” —Dr. Ryan Robinson, Pain and Sleep Therapy Center
Once a patient is diagnosed with sleep apnea, many doctors prescribe the use of a continuous positive airway pressure (CPAP) device. These, however, present their own challenges.
“The CPAP allows you to breathe by breathing air into you. It treats you like a balloon. Compliance is an issue with the CPAP because people just don’t wear it,” Swiatowicz says.
It’s sometimes a case of the treatment being worse than the underlying problem, says Dr. Philip Pike of the Wilmington-based Dental Health Associates.
“Many people are CPAP-intolerant and can’t stand a mask over their face, or the noise of the machine,” he says.
The expertise of a dentist comes into play when the patient opts for a dental appliance rather than a CPAP to help relieve their sleep breathing disorder.
“And then we will do probably the most comprehensive exam they’ve sat through,” Swiatowicz laughs. “We will examine the muscles of the head and neck, range of motion … and I’ll look up their nose. We want to observe what the nasal cavity looks like.” His office is equipped to take digital models of the mouth, “so there’s no goopy impressions they have to go through.”
Research on sleep breathing disorders is “really in the toddler ages,” says Robinson, who notes that more awareness will eventually lead to more effective treatment.
“This stuff was really just found out about in the 1980s. We really don’t have long-term data like with cardiovascular disease or other things we’ve known about for a long time,” he says. “About 80 to 90 percent of people walking around with this condition don’t even know about it. Until we get the education about how to screen for this, we really aren’t doing our jobs as well as we could have.”
To find professionals qualified in sleep dentistry or American Academy of Dental Sleep Medicine diplomats in Delaware, visit aadsm.org.
Published as “Taking a Bite Out of Bad Sleep” in the June 2020 issue of Delaware Today magazine.