JDSM

ORIGINAL ARTICLES http://dx.doi.org/10.15331/jdsm.7044

A New Definition of Dental Sleep Medicine

Frank Lobbezoo, DDS, PhD1, Ghizlane Aarab, DDS, PhD1, Peter Wetselaar, DDS, PhD1, Aarnoud Hoekema MD, DMD, PhD1,2,3,
Jan de Lange, MD, DDS, PhD4 & Nico de Vries, MD, PhD1,5,6

1Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amster-

dam, Amsterdam, The Netherlands, 2Department of Oral and Maxillofacial Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands, 3De-
partment of Oral and Maxillofacial Surgery, University Medical Groningen Hospital, Groningen, The Netherlands, 4Department of Oral and Max-
illofacial Surgery, Academic Medical Center (AMC) and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and
Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, 5Dept. of Otorhinolaryngology, Head and Neck Surgery OLVG West, Amsterdam,
The Netherlands, 6Faculty of Medicine and Health Sciences. Dept. of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital
(UZA), Antwerp, Belgium

Dental Sleep Medicine is the discipline concerned with the study of the oral and maxillofacial causes and consequences of sleep-related
problems. Within the framework of this newly proposed definition, the discipline covers the following conditions: orofacial pain; oral
moistening disorders (oral dryness, hypersalivation); gastro-esophageal reflux disorder; sleep-related breathing disorders (snoring, ob-
structive sleep apnea); and mandibular movement disorders (dyskinesia, dystonia, sleep bruxism). This article briefly outlines these
conditions, with particular emphasis on whether they have adverse effects on patients, and when a condition should be regarded as a
disorder and therefore diagnosed and if necessary managed. This is found to be the case with virtually all these conditions, except with
sleep bruxism, which does not have adverse effects on everyone, in which case it counts as ‘behavior’. Diagnosing and managing behavior
is controversial, especially since sleep bruxism also appears to have positive effects. A cautious approach is therefore called for.

Keywords: dentistry, sleep medicine, disorder, behavior, multidisciplinary

Citation: Lobbezoo, F, Aarab G, Wetselaar P, et al. A new definition of dental sleep medicine. J Dent Sleep Med. 2018;5(4):109-112.

INTRODUCTION article therefore propose the following definition:

‘Dental Sleep Medicine is the discipline concerned
Dental Sleep Medicine, an offshoot of Dentistry and
with the study of the oral and maxillofacial causes and con-
more specifically of Oral Medicine, is highly multidiscipli-
sequences of sleep-related problems.’
nary and requires a lot of specialist medical knowledge on
the part of those working in it, including on ear, nose and This broadens the subject area to other problems
throat medicine, neurology, lung disease, and internal med- where dentistry can (or should) play a role. Credit is due to
icine. This challenging discipline is practiced mainly by Lavigne et al. (2), who produced a publication on this dis-
maxillofacial surgeons, orthodontists, and dentists special- cipline almost two decades ago. In their view, Dental Sleep
ized in oral medicine, dental sleep medicine, or orofacial Medicine covers the following disorders:
pain and dysfunction. • Orofacial pain
Dental Sleep Medicine is an up-and-coming disci-
• Oral moistening disorders (including oral dryness
pline, as is reflected both nationally and internationally in
and hypersalivation)
the founding of professional scientific associations (e.g.,
European Academy of Dental Sleep Medicine – EADSM; • Gastro-esophageal reflux disorder (GERD)
American Academy of Dental Sleep Medicine – AADSM), • Sleep-related breathing disorders (including snor-
the recent publication of specialized textbooks (1), and ing and OSA)
even a peer-reviewed scientific journal (the Journal of Den- • Mandibular movement disorders (including dyski-
tal Sleep Medicine). The AADSM came up with a defini- nesia, dystonia and sleep bruxism)
tion of the discipline in 2008: ‘Dental Sleep Medicine fo- These disorders are briefly outlined below. Details can be
cuses on the management of sleep-related breathing disor- found in textbooks like “Sleep Medicine for Dentists: A
ders (SBD), which includes snoring and obstructive sleep Practical Overview” (1) and “Principles and Practice of
apnea (OSA), with oral appliance therapy (OAT) and upper Sleep Medicine” (3). Only for specific details, references
airway surgery.’1 Dental Sleep Medicine covers more than are provided.
just breathing disorders, however, and the authors of this

1
http://www.aadsm.org/
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 A New Definition of Dental Sleep Medicine – Lobbezoo et. al

OROFACIAL PAIN
GASTRO-ESOPHAGEAL REFLUX DISORDER
There are many types of orofacial pain: it can be (GERD)
dento-alveolar (i.e., due to problems with the teeth and the
surrounding supporting tissue), musculoskeletal (due to Gastro-esophageal reflux disorder (GERD) is de-
muscle or joint problems), or neuropathic (due to nerve tis- scribed as retrograde flow of gastric acid into the distal
sue problems). Headache is also classified as a type of oro- esophagus, larynx, pharynx, and even the oral cavity. The
facial pain. They can all affect sleep, for example by mak- commonly used Montreal definition, a global evidence-
ing it difficult to fall asleep or by causing nocturnal waking. based consensus definition for GERD (12), adds to this de-
All this can result in waking unrested, lowered energy lev- scription that the reflux of stomach contents should cause
els, fatigue, lowered resistance, irritated bowels, and even troublesome symptoms and/or complications. Patients re-
feelings of depression. Nor is it the case that orofacial pain port GERD as heartburn that disturbs sleep, and they may
causing sleep problems is a one-way process; poor sleep also complain of an acid taste in the mouth. In addition,
can conversely cause orofacial pain. The precise relation- patients with GERD often report foreign body sensation,
ship between the two phenomena differs from one person painful throat and hoarseness, and other aspecific throat
to another. For an overview, see De Leeuw & Klasser (4). complaints. The prevalence of GERD varies from 20% to
40% and is associated with increasing costs for health care
(13). Further, epidemiological research shows that about
ORAL MOISTENING DISORDERS 10% of the general population suffer from GERD at least
once weekly (14), so it is a substantial problem. Factors
This category includes oral dryness and hypersaliva- that can cause GERD, as well as failure of the lower esoph-
tion. For an overview, see Lavigne et al. (2). ageal sphincter and diaphragmatic hernia, include obesity
and pregnancy. GERD has substantial effects on the indi-
Oral dryness vidual: it can cause erosive (chemical) tooth wear, resulting
Oral dryness can be an actual dryness of the oral cav- in sensitive teeth, and it can promote hypersalivation, pos-
ity due to for instance hyposalivation or the feeling of a dry sibly resulting in aspiration pneumonia. GERD is also as-
mouth. The latter condition is coined “xerostomia” (5,6). sociated with OSA and even premalignant or malignant
The unpleasant feeling of dryness is experienced in the oral mucosal lesions in the esophagus. For an overview, see
cavity and throat. Its prevalence is substantial: about a Lavigne et al. (2).
quarter of the population suffer from oral dryness to a
greater or lesser degree at some point in their lives (7). The SLEEP-RELATED BREATHING DISORDERS
following are often identified as possible causes: mouth
breathing; medical conditions such as diabetes, Sjögren’s This category includes snoring and obstructive sleep
syndrome, OSA and GERD; and medication (many drugs apnea (OSA). For an overview, see Lavigne et al. (2).
cause a feeling of dry mouth) (8). Oral dryness can cause
repeated nocturnal waking, which patients often use to Snoring
have a drink. All in all, then, oral dryness substantially dis- This familiar condition is characterized by loud
turbs normal sleep patterns. breathing sounds produced in the upper airway during
sleep. It is a common problem, which increases with age
Hypersalivation until the point is reached where about half of men and
Hypersalivation is excessive saliva production, which women over the age of 65 snore regularly. Where OSA is
means that there is an imbalance between saliva production absent the effects are mainly social, with bed partners in
and swallowing frequency. Swallowing frequency is in fact particular suffering from sleep disturbance, which can be
lower during sleep than waking: a person swallows about severe. The effects can therefore be substantial. In load
three times an hour on average during sleep (9), whereas snoring individuals, a sleep study has to be considered
the frequency during waking is at least once every two since it is the most important alarm symptom for OSA (15).
minutes (10). Patients with hypersalivation often complain
that the pillow is wet. The prevalence is substantial at 8%, Obstructive Sleep Apnea (OSA)
albeit lower than that of oral dryness (7). Possible causes OSA is characterized by repeated obstruction of the
are medical conditions such as Parkinson’s disease (11), upper airway, causing oxygen desaturation and frequent
periodontal problems, poorly fitting or loose dentures and awakenings of the patient. 14-49% of middle-aged men in
once again a whole range of drugs. Hypersalivation also the United States and Europe have clinically significant
causes repeated nocturnal waking, with all the adverse ef- OSA (16). The etiology is multifactorial and still not fully
fects of sleepiness during the day and so on. It can also clarified: associations have been found with various demo-
cause aspiration, resulting in coughing or even aspiration graphic, anatomical, biological and behavioral factors. The
pneumonia. effects are substantial: OSA can cause the patient to wake
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 A New Definition of Dental Sleep Medicine – Lobbezoo et. al

unrested, excessive fatigue during the day, high blood pres- ditions described above could also be referred to as ‘behav-
sure, cardiovascular disease, cognitive impairment, re- ior’, however. Behavior is only a disorder if it causes some
duced libido, and a whole range of other health problems, kind of harm or is detrimental to the individual; if this is
some of them severe (including mortality). For an over- not the case it is simply behavior, and diagnosis and man-
view, see Lavigne et al. (2). agement are not indicated (21). Which of the conditions de-
scribed above can justifiably be referred to as disorders? In
MANDIBULAR MOVEMENT DISORDERS effect they may all have serious effects on the individual.
The only case where this does not seem to apply is snoring
This category includes dyskinesias, dystonias and (without OSA): here the harm is mainly to the bed partner,
sleep bruxism. For an overview, see Michelotti et al. (17). if any. However, since this in turn has social consequences
for the snorer, it makes snoring behavior a snoring disorder
Orofacial dyskinesias for the individual concerned, and diagnosing and if neces-
This group of motor dysfunctions is characterized by sary managing it is then justifiable. In addition, it should
involuntary, mainly choreatic (dance-like) movements of again be noted that loud snoring is the most important
the face, lips, tongue and jaws. If the condition is confined alarm system for OSA, hence justifying additional diagnos-
to the jaws it is important to differentiate it from bruxism- tic procedures as well. The situation is somewhat more
related teeth grinding (18). Possible causes can be underly- complicated with sleep bruxism. As already said, not all
ing psychiatric disorders and certain drugs (e.g., neurolep- bruxists experience adverse effects from their behavior. Di-
tics and dopamine-related drugs). Orofacial dyskinesia has agnosis and management are not appropriate for them, first
an enormous impact on everyday life, but not enough is yet and foremost to avoid “overdiagnosis” and ”overmanage-
known about the local effects. Patients with this disabling ment”, but also because there are some indications that
condition can also have disturbed sleep. bruxism – in addition to the supposed adverse effects – can
also have positive effects on the individual, such as stimu-
Oromandibular dystonias lating salivation (thus preventing dry mouth during sleep)
Where these excessive, involuntary, persistent muscle and helping to maintain adequate muscle tone in the upper
contractions in the lips, tongue, and jaws are confined to airway (thus possibly preventing OSA) (22).
the latter structure, they can easily be confused with brux-
ism-related clenching (18). This is nevertheless a genuine CONCLUSION
and potentially disabling motor dysfunction, which has the
same possible causes and effects as the orofacial dyskine- The newly proposed definition of Dental Sleep Medi-
sias outlined above. cine enables the inclusion of not only sleep-related breath-
ing disorders into this dental discipline, but also of other
Sleep bruxism conditions that may have oral and maxillofacial causes and
Bruxism has recently been defined as repetitive mas- consequences. Although the recent founding of dedicated
ticatory muscle activity characterized by clenching or professional Academies suggests that Dental Sleep Medi-
grinding the teeth and/or bracing or thrusting the mandible cine is a genuine new offshoot of Dentistry, some will con-
(19). Although bruxism can also occur during the day sider the discipline as part of wider discipline “Oral Medi-
(awake bruxism), here we shall briefly consider sleep brux- cine”. However, since Oral Medicine as a dental discipline
ism, referring to the review by Lobbezoo et al. (20). The does not exist in every country, and if it does, is not always
prevalence of sleep bruxism in the general population is widespread, the authors of this article consider the exist-
8%. A variety of factors play a role in the multifactorial ence of Dental Sleep Medicine as a separate dental disci-
etiology: psychosocial (stress, anxiety), biological (neuro- pline justified, the more so since many of the above out-
transmitter abnormalities, genetics), and exogenous (med- lined conditions deserve more attention from dental profes-
ication, smoking, alcohol). The following are identified as sionals.
possible effects: breakage or loss of teeth, fillings or im- Most of the conditions that fall into the category of
plants; mechanical tooth wear in the form of attrition; mas- Dental Sleep Medicine are disorders (i.e., they have ad-
ticatory muscle hypertrophy; musculoskeletal pain; and verse effects on the individual) and should therefore be di-
mandibular dysfunctions. It should be stressed that some agnosed and if necessary managed. The exception is sleep
bruxists do not experience any of these adverse effects. bruxism, which does not always harm the patient. For this
reason – and because sleep bruxism also appears to have
DISORDER OR BEHAVIOR? positive effects on the individual – a cautious approach is
called for when diagnosing and managing bruxism behav-
The conditions described above are frequently re- ior.
ferred to as ‘disorders’, and a disorder should by definition
be diagnosed and if necessary managed. A few of the con-

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ACKNOWLEDGMENTS
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16. Garvey JF, Pengo MF, Drakatos P, Kent BD. Epidemiological as- Medical Advisor of Zephyr Sleep Technologies. Nico de
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C, Schiffman E, List T. Next steps in development of the diagnostic and stock options in ReVent, and is researcher for Inspire.
criteria for temporomandibular disorders (DC/TMD): Recommenda-
tions from the 2014 International RDC/TMD Consortium Network Ghizlane Aarab, Peter Wetselaar, and Jan de Lange report
workshop. J Oral Rehabil 2016;43:453-467. no conflicts of interest.
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