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Quality sleep is one of the fundamental building blocks for optimum health, right along with healthy food and clean water.1 Poor sleep quality is often unrecognized in children and adults and generally manifests as oral and systemic health issues, concentration problems, undesirable attitudes or behaviors, depression, and daytime sleepiness.1-3
The first step to improving sleep quality is to recognize there might be a problem. Poor sleep quality is a complex issue that can include many factors, such as poor sleep hygiene, abnormal oral structures, oral pain, oral myofunctional disorders, systemic health issues, and/or obstructive sleep apnea (OSA).1,4-7
During preventive and therapeutic appointments, dental hygienists are gathering information about a person's oral health that can also help identify possible sleep quality concerns including lifestyle, health history, and intra and extraoral examinations.8 The next steps to providing optimal patient care are processing the acquired assessment information into a dental hygiene diagnosis, providing patient education regarding the oral/systemic health concern, and confidently referring the patient to an allied health care professional.8
Overview of Sleep and Importance of Oral and Systemic Health
Sleep is a vitally important and complex process of rapid eye movement (REM) and non-rapid eye movement (NREM) stages that is regulated by the central nervous system to repair the body and mind.1 An optimal night of sleep cycles through many variations of NREM and REM sleep every 60-90 minutes.1 NREM sleep is primarily associated with rejuvenation of the body, including heart repair and the lowering of blood pressure.1 REM sleep is primarily associated with rejuvenation of the mind, including memory processing and emotion regulation.1,3
Situations that disrupt sleep might range from easily remedied sleep hygiene factors to serious and complex issues such as OSA.1 Sleep hygiene relates to extrinsic factors such as being exposed to electronics, blue light or daylight, or disruptions from other people or pets while trying to sleep.1,7,9,10
Structural and oral myofunctional disorders often have a cyclical cause-and-effect relationship.6,11 Poor oral development caused by factors such as ankyloglossia, chronic allergies, enlarged tonsils, or weak facial muscles can affect facial growth, change dentition position, and contribute to poor sleep quality.6,11,12 If interventions such as tongue release, allergy therapy, tonsil removal, orthodontics and/or oral myofunctional therapy do not occur, there may be permanent changes in an individual's face, oral function, and sleep quality.4,6,11,12
Obstructive sleep apnea (OSA) is a condition where an individual's airway collapses during the sleep cycle, causing a lack of oxygen to the brain.1 When O2 levels become too low, the brain signals the individual to wake up and breathe, causing a break in the sleep cycle.1,13 Not only does this process strain the heart and body systems, it also prevents the individual from reaching the deeper stages of sleep where body and brain repair occurs.1,13 OSA risk factors are often identified in middle-aged men with large neck, chest and abdomen circumference who snore and experience daytime sleepiness. Recent evidence suggests that men, women and children regardless of shape, size, or age could also be at risk for poor sleep quality or even OSA.13-16
The Dental Hygiene Process of Care Can Help Identify Sleep Quality Concerns
The American Dental Hygienists' Association Standards for Clinical Dental Hygiene Practice include assessments that should be provided by dental hygienists during standard oral care.8 This article focuses on the assessments that directly relate to a possible sleep quality issue.
Key factors that might contribute to a sleep quality concern are systemic health issues such as high blood pressure, cardiac disease, type 2 diabetes, attention deficit hyperactivity disorder, depression, anxiety, acid reflux, and allergies.
Patient history.8 Assessment of a patient's well-being begins the moment that patient is greeted in the waiting room. Does the patient appear to be feeling well? Do they seem to be in a pleasant and friendly mood? Part of our initial assessment is getting to know more about the patient's lifestyle. Do they work shift-work? Have small children? What is their marital status? Do they have pets in the house? Does this person have a hard time holding down a job, managing relationships, or concentrating in work or school?
Health history.8 Other clues to sleep quality concerns could be indicated in the medical history. Key factors that might contribute to a sleep quality concern are systemic health issues such as high blood pressure, cardiac disease, Type 2 diabetes, attention deficit hyperactivity disorder, depression, anxiety, acid reflux and allergies.1,2,12 Other health concerns associated with poor sleep are an inability to lose weight, chronic inflammatory diseases (such as atopic dermatitis or asthma) and restless leg syndrome.1,14,17
Extraoral examination.8 Facial features that might indicate an oral myofunctional disorder 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 corners of the mouth, long and narrow face, gummy smile, bad breath, and dark circles under the eyes.6,11
Intraoral examination.8 This portion of the assessment process might reveal additional signs and symptoms relating to poor sleep quality including gingivitis, active periodontal disease, poor plaque control, dry mouth or excessive saliva, increased caries risk, poor occlusion, enlarged tonsils, and high narrow hard palate.6,11 Additionally, ankyloglossia can prevent the tongue from properly swiping the teeth and soft tissues of the mouth for proper food control and prevents the tip of the tongue from properly resting against the hard palate during sleep.6,7,18 A large wide tongue with scalloped edges might indicate that the patient is using the tongue to protect the airway while sleeping.6,7,18 Enlarged tonsils might be a factor in mouth breathing during both waking and sleeping events that lead to oral myofunctional disorders and poor sleep quality.7 Missing teeth or edentulousness can contribute to the inability to close the lips properly during sleep and may prevent C-PAP masks from fitting properly.19
Risk assessments.8 If, after gathering all the pieces of the dental hygiene assessment, the clinician suspects a sleep quality issue, the next step is to ask the patient if they sleep well and administer a sleep quality questionnaire. There are many beneficial sleep quality questionnaires available, including the Pittsburgh Sleep Quality Index, the Functional Outcomes of Sleep Questionnaire and the Epworth Sleep Scale.20,21 These tools are useful to bring sleep quality awareness to the patient and provide documentation in the patient's dental chart, and as a communication tool when referring to an allied health professional.
Dental hygiene diagnosis.8 Based on the evidence, critical analysis, and professional interpretation of the dental hygiene assessments, the dental hygienist is in the ideal position to identify a poor sleep quality concern that may need further evaluation from an allied health professional.8 If a dental hygiene diagnosis is not made, then the next steps of planning, referring, and documenting would not have a logical basis and might not help our patients receive proper oral or systemic health care.8
Planning and referral process.8 A referral to an advanced oral health provider or primary care provider is warranted if the patient has a sleep quality concern that cannot easily be remedied with improved sleep hygiene. The patient should receive a referral to their primary care provider (PCP) or other allied health care professional explaining the reason for the sleep quality concern using evidence from the dental hygiene assessment and including a copy of the sleep quality questionnaire. In areas of serious concern, the dentist or dental hygienist should contact the PCP directly.
Allied health professionals who might be able to help with sleep quality concerns such as allergies, oral myofunctional disorders, and OSA include PCPs, pulmonologists, allergists, otolaryngologists, oral surgeons, orthodontists, oral myofunctional therapists, speech language pathologists, and/or dental professionals who specialize in alternative airway appliances.1,4,11,12
Evaluation and documentation.8 Properly document all concerns and actions taken in the patient chart. Be sure to follow up with the patient at the next scheduled visit to determine if actions have been taken to remedy sleep quality concerns. Perform new assessments to determine if the patient's oral health has improved in response to sleep quality changes. If the patient exhibits or reports no improvements, consult with the patient and dentist to determine if further measures are warranted.8
Oral health professionals are in the prime position to identify sleep quality concerns in our patients, regardless of age, gender or body composition. By identifying, educating, and referring patients for further evaluation, dental hygienists can help improve oral and systemic health and improve their overall quality of life. Sleep quality is a complex and multi-factorial topic. The reader is strongly encouraged to seek continuing education courses on the topics of sleep quality, oral myofunctional disorders, oral anatomy and physiology review, and/or OSA.
About the Author
Kelly Schroeder, RDH, MS, is a clinical dental hygienist at Smiles By Design, Hortonville, Wisconsin, and also a dental hygienist-researcher with Marshfield Clinic's Center for Oral and Systemic Health, Marshfield, Wisconsin. She has been published in Access magazine, Dimensions of Dental Hygiene, Decisions in Dentistry, and the Journal of Agromedicine. Her professional goals are to blur the lines between oral and systemic health and highlight dental hygienists as primary care providers. She can be reached at firstname.lastname@example.org.
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