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Sleep and Pain: Raising Awareness for Proper Treatment

12 August 2016

Sleep and Pain: Raising Awareness for Proper Treatment

Sleep and Pain: Raising Awareness for Proper Treatment

When people think of dentistry they often think of merely teeth and gums. However, dentistry has advanced to more than just oral health to overall health as well. With that in mind, it is important to raise awareness of dental sleep medicine (sleep apnea and snoring), as well as pain, such as TMD and craniofacial pain.

Currently, tooth decay affects more than one-fourth of children in the UK between the ages of 2 and 5. As children get older, this number changes to one-third of 12-year-olds and more than a quarter of 15-year-olds. Even more alarming is that approximately 1 in 30 people in the UK complain about headaches each year and it is estimated that around 1.5 million adults have OSA, although only around 330,000 are currently diagnosed and treated. These numbers are increasing as obesity levels rise in adults and children. In a UK cross sectional study, 12 per cent of children were found to be habitual snorers and 0.7 per cent were found to have obstructive sleep apnoea[13].

By looking at these numbers we can see just how important it is for dentists to continue their education – there is a wide pool of patients you might be missing that need a dentist’s help. When a dentist begins to offer services in dental sleep medicine and craniofacial pain, he or she can begin to create more opportunity for their entire practice to help treat patients while improving their overall quality of life.

Understanding Sleep Apnea and Snoring

Obstructive sleep apnoea (OSA) is a sleep related respiratory condition, leading to intermittent cessations of breathing due to a narrowing or closure of the upper airway during sleep. Symptoms of OSA often include excessive daytime sleepiness, snoring, and witnessed apnoeas or hypopnoeas (collapse of the airway leading to breathing cessations). Although OSA is thought to be a disorder affecting the overweight or obese, it can affect anyone and is estimated to affect 1.5 million adults in the UK, men, women and children.

Even more alarming is that 85% of adults in the UK go undiagnosed and untreated – that number is far too high. And, while awareness of OSA is rising, about 42% of people who snore or whose partner snores, have not even heard of OSA. With general population awareness levels so low, it is the duty of dentists in the UK to provide effective care and education as stated by the British Lung Foundation. We as dentists are in a prime position to not only raise awareness and provide education but also to guide our patients to receiving appropriate treatment either with oral devices or other treatment options such as continuous positive airway pressure (CPAP) machines.

Craniofacial Pain and TMD

TMD refers to a group of disorders affecting the temporomandibular joint (TMJ), masticatory muscles and the associated structures. Common symptoms of TMD include pain, limited mouth opening and joint noises (also known as clicking of the jaw).

TMD symptoms affect up to 25% of the population with only 5% seeking medical help for their symptoms – they simply “put up with” the pain or can’t find a treatment[1]. TMD can occur at any age, but is more common among women and those between the ages of 20 and 50.

The main sensory nerve system running through the head is the trigeminal nerve system and accounts for 90% of all the sensory input into the entire nervous system. Because of this we can explain why TMD can sometimes lead to debilitating symptoms for those who suffer from this condition. Many patients will seek treatment for craniofacial pain due to recurring migraines, but 90% of headaches are really caused by disorders in the facial muscles and nerves.

A Connection Between Sleep Apnoea and Pain

As research continues to advance we can see a clear connection between sleep disordered breathing, craniofacial pain and TMD, which means proper evaluation and diagnosis by the dental and medical teams is essential. Essentially, though, it’s up to the dental clinician to determine this because it is the dentist who will often evaluate, refer and possibly manage these issues impacting such a large percentage of the population.

There is ample evidence to suggest that sleep apnoea and pain are related, but many questions still remain. One main trend emerging pertains to the directionality and mechanisms of the association of sleep apnoea and chronic pain. It appears that sleep disturbance may impair key processes that contribute to the development and maintenance of chronic pain, including joint pain (TMD). In a recent study, sleep disturbance and pain were connected. It determined that pain not only has direct effects on the person’s health, but also an association with sleep disturbances

Many studies have suggested that experimental sleep disruption results in enhanced pain perception and interactions between sleep and pain. It is suggested that experimental sleep disruption results in enhanced pain perception, that poor sleep is correlated with elevated pain severity in chronic pain patients and that in the general population, individual differences in sleep impact on subsequent pain. A study published in the European Journal of Pain stated that sleep fragmentation among healthy adults resulted in subsequent decrements in endogenous pain inhibition[2].

With an evident relationship, we look to understand that clenching or grinding of one’s teeth is a way for the brain to protect itself from suffocation during sleep[3-7]. The screening process is important in helping us identify bruxism as either a cause of TMJ/craniofacial pain or a protective mechanism in sleep disordered breathing[8-11]. By identifying this link between the three conditions we can properly manage each disorder.

Dental Solutions for Proper Treatment

Patients who suffer from severe sleep apnoea might opt for surgery for treatment. However, sleep apnoea surgeries have a history of causing the patient excruciating pain. The gold standard for severe obstructive sleep apnea (OSA) patients is use of the CPAP machine, with success ranging in various studies from 90 to 95%. However, the problem with CPAP treatment is patient compliance and tolerance. When people return home, there is a good chance they just won’t use their machine[12].

There are challenges posed by sleep apnoea and craniofacial pain which span the research spectrum. From causes to diagnosis through treatment and prevention. It is important to work together to gain a better understanding of sleep apnoea, the TMJ and muscle disease process and craniofacial pain, as well as improving quality of life for people affected by these disorders.

Dentists see their patients more often than family doctors since it is recommended that patients visit a dentist at least twice a year. Since we are typically seeing our patients more often, it is important to understand sleep apnoea, TMD and craniofacial pain, as well as gaining an understanding of the right questions to ask.

Seeing as only 1 out of 20 patients suffering from pain actually seek treatment in the UK and that 85% of patients with sleep apnoea either don’t or do not know where to seek help, it is vital that we ask the right questions in order to gain a proper diagnosis because if they are suffering from pain they might not realize the solution can be found at the dental practice:

  • Palliative care - medications to better improve a patient’s pain.
  • Changing a patient’s diet - this would include soft foods or foods that don’t overextend the jaw or cause pressure on the head. For sleep apnoea it would include foods to help in weight control or loss.
  • Oral appliance therapy and orthodontics - offer a way to realign the jaw and teeth to relieve pressure on the face and jaw while preventing the tongue from falling over the airway.

Dentists hold the key to successful management of sleep apnoea and pain among patients who might think a solution is not possible. It is our responsibility to continue to advance our knowledge of various areas of dentistry we might not be exposed to in our undergraduate training--there is more out there than we were taught.

Advanced Education

As dentists we must look to better understand sleep apnoea, snoring and craniofacial pain in order to provide our patients with the care they need to live a good quality of healthy and happy lives. Further education through lectures and seminars becomes essential with a wide range of continuing education courses available. Only through continuing education can we continue to offer the help that patients with this debilitating condition need.

Since this is not a subject that is covered in undergraduate curriculum, post-graduation certification in dental sleep medicine and craniofacial pain allows the whole team to engage with various medical and dental specialties to offer the optimum management options to these patients.

Don’t let patients settle with just dealing with their sleep apnoea and pain, help them get the care they need and deserve.

The British Society of Dental Sleep Medicine provides such courses, having recently introduced TMD and craniofacial pain as a module in its training courses.

1. Murphy, M.K., et al., Temporomandibular Joint Disorders: A Review of Etiology, Clinical Management, and Tissue Engineering Strategies. The International Journal of Oral & Maxillofacial Implants, 2013. 28(6): p. e393.

2. Edwards, R., et al., Sleep continuity and architecture: Associations with pain-inhibitory processes in patients with temporomandibular joint disorder. European Journal of Pain, 2009. 13(10): p. 1043-1047.

3. Ng, D.K., et al., Prevalence of sleep problems in Hong Kong primary school children: a community-based telephone survey. Chest, 2005. 128(3): p. 1315-1323.

4. Phillips, B., et al., Effect of sleep position on sleep apnea and parafunctional activity. Chest, 1986. 90(3): p. 424-429.

5. Bailey, D.R., Sleep disorders. Overview and relationship to orofacial pain. Dental clinics of North America, 1997. 41(2): p. 189-209.

6. Hosoya, H., et al., Relationship between sleep bruxism and sleep respiratory events in patients with obstructive sleep apnea syndrome. Sleep Breath, 2014. 18(4): p. 837-44.

7. Saito, M., et al., Temporal association between sleep apnea-hypopnea and sleep bruxism events. J Sleep Res, 2013.

8. Blanco Aguilera, A., et al., Relationship between self-reported sleep bruxism and pain in patients with temporomandibular disorders. J Oral Rehabil, 2014. 41(8): p. 564-72.

9. Manfredini, D. and F. Lobbezoo, Relationship between bruxism and temporomandibular disorders: a systematic review of literature from 1998 to 2008. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 2010. 109(6): p. e26-e50.

10. Unell, L., et al., Changes in reported orofacial symptoms over a ten-year period as reflected in two cohorts of fifty-year-old subjects. Acta Odontol Scand, 2006. 64(4): p. 202-8.

11. Ahlberg, K., et al., Perceived orofacial pain and its associations with reported bruxism and insomnia symptoms in media personnel with or without irregular shift work. Acta Odontol Scand, 2005. 63(4): p. 213-7.

12. Richard, W., et al., Acceptance and long-term compliance of nCPAP in obstructive sleep apnea. European Archives of Oto-Rhino-Laryngology, 2007. 264(9): p. 1081-1086.

[i]13. Ali NJ, Pitson DJ, Stradling JR. Snoring, sleep disturbance, and behaviour in 4-5 year   olds. Arch Dis Child 1993; 68(3): 360-6.

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