Sleep Medicine for Dentists: A Practical Overview
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Sleep Medicine for Dentists - Gilles J. Lavigne
Sleep Medicine for Dentists
A Practical Overview
SLEEP MEDICINE FOR DENTISTS
A PRACTICAL OVERVIEW
Edited by
Gilles J. Lavigne, DMD, MSc, PhD, FRCD(C)
Professor of Oral Medicine and Canada Research Chair in Pain, Sleep and Trauma
Dean, Faculty of Dental Medicine
University of Montreal
Sleep and Biological Rhythm Center and Department of Surgery
Montreal Sacré-Coeur Hospital
Montreal, Quebec, Canada
Peter A. Cistulli, MBBS, PhD, MBA, FRACP
Professor of Respiratory Medicine
Head, Discipline of Sleep Medicine
University of Sydney
Research Leader, Woolcock Institute of Medical Research
Director, Centre for Sleep Health and Research
Royal North Shore Hospital
Sydney, New South Wales, Australia
Michael T. Smith, PhD, CBSM
Associate Professor of Psychiatry and Behavioral Sciences
Director, Behavioral Sleep Medicine Program
Johns Hopkins University School of Medicine
Baltimore, Maryland
9780867155448_lavigne_0003_001Library of Congress Cataloging-in-Publication Data
Sleep medicine for dentists : a practical overview / edited by Gilles J.
Lavigne, Peter A. Cistulli, Michael T. Smith.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-86715-487-0 (hardcover)
eISBN 978-0-86715-931-8
1. Sleep disorders. 2. Dentistry. I. Lavigne, Gilles J. II. Cistulli, Peter A. III. Smith, Michael T. (Michael Timothy), 1967-
[DNLM: 1. Sleep Disorders--diagnosis. 2. Dentistry--methods. 3. Mouth
Diseases--complications. 4. Sleep Disorders--etiology. 5. Sleep
Disorders--therapy. 6. Tooth Diseases--complications. WM 188 S632394 2009]
RC547.S5474 2009
616.8'498--dc22
2009015149
9780867155448_lavigne_0004_001© 2009 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Editor: Bryn Goates
Cover and internal design: Gina Ruffolo
Production: Patrick Penney
Printed in Canada
9780867155448_lavigne_0005_001Dedication
Foreword, by Colin E. Sullivan
Foreword, by George A. Zarb and Barry J. Sessle
Preface
Contributors
Section I Introduction to Dental Sleep Medicine
1The Nature of Sleep
Gilles J. Lavigne, Charles M. Morin, Maria Clotilde Carra
2Sleep Neurobiology
Florin Amzica, Gilles J. Lavigne
3Classification of Sleep Disorders
Gilles J. Lavigne, Raphael C. Heinzer, Peter A. Cistulli, Michael T. Smith
Section II Sleep Breathing Disorders
4Sleep-Related Breathing Disorders
Andrew S. L. Chan, Richard W. W. Lee, Peter A. Cistulli
5Pathophysiology of Obstructive Sleep Apnea
Andrew S. L. Chan, Richard W. W. Lee, Gilles J. Lavigne, Peter A. Cistulli
6Long-term Consequences of Obstructive Sleep Apnea
Craig L. Phillips, Keith Wong
7Clinical Approach to Diagnosis of Obstructive Sleep Apnea
Richard W. W. Lee, Andrew S. L. Chan, Peter A. Cistulli
8Upper Airway Imaging in Obstructive Sleep Apnea
François-Louis Comyn, Richard J. Schwab
9An Overview of Obstructive Sleep Apnea Treatment
Peter R. Buchanan, Ronald R. Grunstein
10 Oral Appliances
Marie Marklund, Peter A. Cistulli
11 Dentofacial Orthopedics
M. Ali Darendeliler, Lam L. Cheng, Paola Pirelli, Peter A. Cistulli
Section III Sleep Bruxism and Movement Disorders
12 Definitions, Epidemiology, and Etiology of Sleep Bruxism
Frank Lobbezoo, Ghizlane Aarab, Jacques van der Zaag
13 Orofacial Movement Disorders in Sleep
Takafumi Kato, Pierre J. Blanchet
14 Clinical Approach to Diagnosis of Sleep Bruxism
Kiyoshi Koyano, Yoshihiro Tsukiyama
15 Pathophysiology of Sleep Bruxism
Gilles J. Lavigne, Henri Tuomilehto, Guido Macaluso
16 Sleep Bruxism in Children
Nelly Huynh, Christian Guilleminault
17 Management of Sleep Bruxism
Ephraim Winocur
Section IV Sleep and Orofacial Pain
18 Pathophysiologic Conceptualizations of Chronic Pain
Claudia M. Campbell, Robert R. Edwards
19 Mechanisms of Sleep Loss–Pain Interactions
Monika Haack, Jennifer Scott-Sutherland, Navil Sethna, Janet M. Mullington
20 Clinical Implications of Sleep Loss–Pain Interactions
Monika Haack, Jennifer Scott-Sutherland, Navil Sethna, Janet M. Mullington
21 Association of Orofacial Pain Conditions and Sleep Disturbance
Peter Svensson, Lene Baad-Hansen, Taro Arima
22 Impact of Common Temporomandibular Disorder Comorbidities on Sleep Quality and Orofacial Pain
Luis F. Buenaver, Edward G. Grace
23 Pharmacologic Management of Sleep-Pain Interactions
Brian E. Cairns, Parisa Gazerani
24 Nonpharmacologic Management of Insomnia and Pain
Nicole K. Y. Tang, Michael T. Smith
Conclusion, by Alan A. Lowe
To our students and research associates
who have contributed to the progress in dental sleep medicine
9780867155448_lavigne_0008_001Healthy sleep is vital for mental and physical well-being, and yet our understanding of the mechanisms that link sleep processes and brain and body function is relatively new. Until the discovery of rapid eye movement (REM) sleep in the 1950s, sleep was considered a passive state without particular import in the medical context. Today we understand that sleep is an active process that subserves many functions of the brain and body. In 1989, publication of the first book on sleep medicine (The Principles and Practice of Sleep Medicine, edited by Kryger et al) heralded sleep as a specialty in its own right. In a similar way, this new textbook heralds another phase in the development of clinical sleep practice for dental practitioners.
In his historical account of sleep medicine, Bill Dement points out that sleep apnea was overlooked by pulmonologists and otolaryngologists because they did not consider sleep. It was equally true that those doing research in human sleep (mostly neurologists and psychiatrists) also missed sleep apnea because they did not consider breathing. The great irony about the emergence of dental sleep medicine is that generations of dentists have looked in the mouths of countless individuals with sleep-disordered breathing without knowing of the disorder. Given that the dentist is often the first and only health care practitioner to look in the oral cavity, a good knowledge of sleep apnea should be part of the profession’s knowledge base. From a broader perspective, these examples underscore the importance of a multidisciplinary approach; very few centers bring physician, surgeon, and dentist together to develop a management plan.
This book provides a compact introduction to sleep disorders. Appropriately, many chapters focus on sleep-disordered breathing because the dentist has a potentially major role in both its recognition and treatment. While continuous positive airway pressure (CPAP) remains the first-line therapy for sleep apnea, there is an important role for mandibular advancement appliances, which require adequate fitting by a well-informed dentist to be effective.
In addition, we should identify children who are at risk of developing sleep apnea. Approximately 10% of children who snore most nights are likely future apnea patients. Management plans designed to promote the growth of the upper airway and to prevent obesity provide a possibility for real prevention. This will happen only if the dental profession engages actively in the area.
The editors and contributors of this book are to be congratulated on putting together the first comprehensive text on dental sleep medicine.
Colin E Sullivan, AO, MB BS, PhD, FRACP, FTSE, FAA
Professor of Respiratory Medicine
Department of Medicine
University of Sydney
Sydney, New South Wales, Australia
9780867155448_lavigne_0009_001The science and clinical implications of sleep medicine should resonate strongly with the dental profession. Not only does the physiologic and behavioral state of our own and indeed our patients’ sleep experiences involve a significant part of daily life, but dental sleep medicine is a rapidly evolving area of health care. A number of recognized sleep-related disorders have relevance to dental practice, and consequently, the availability of a book devoted to this subject has long been overdue. The book editors and authors collectively have impeccable academic credentials and clinical experience, and they have produced a lucid and apposite synthesis of the many topics that bear on sleep medicine and its particular applicability to dental practice.
The book is organized into four sections that deal first with general aspects of sleep and sleep disorders, then specifically sleep breathing disorders, sleep bruxism and other sleep-related movement disorders, and finally sleep–orofacial pain interactions. The inclusion of an exhaustive range of pertinent topics has ensured a perceptive and balanced approach to the subject. Unlike so many multi-authored texts on equally complex and fascinating health-related subjects, this one provides a mix of science, common sense, and pragmatism, particularly in the review of the management of sleep-related disorders.
We believe that this will prove to be a seminal text for the dental profession. It could very well turn out to be the catalyst required for the subject of dental sleep medicine to be included as an integral part of dental school curricula. The editors are to be commended for breaking new ground and ushering in an era of better understanding of a subject that has been relatively neglected in dental education and practice. Traditional and exclusive preoccupations with teeth, masticatory function, and related disorders—staples of dental education and texts—can now be broadened to include an awareness of our bodies’ more extensive physiology and behavior.
George A. Zarb, BChD, DDS, MS, MS, FRCD(C)
Professor Emeritus
Department of Prosthodontics
Faculty of Dentistry
University of Toronto
Toronto, Ontario, Canada
Barry J. Sessle, MDS, PhD, DSc(hc), FRSC, FCAHS
Professor and Canada Research Chair in Craniofacial Pain and Sensorimotor Function
Faculties of Dentistry and Medicine
University of Toronto
Toronto, Ontario, Canada
9780867155448_lavigne_0010_001The last 50 years have seen remarkable advances in the study of circadian biology and the neurophysiology of sleep. The genes that regulate these biologic rhythms have been isolated, and interactions between sleep and almost all other body systems (eg, respiratory, cardiovascular, endocrine, and neurologic) have become a focus for research. These scientific advances have emanated from diverse clinical disciplines, including internal medicine, pulmonology, neurology, otorhinolaryngology, pediatric medicine, psychiatry, psychology, and nursing. The range in specialties reflects the interdisciplinary nature of sleep and its disorders, and many critical contributions have also come from the field of dentistry. Currently, approximately 100 distinct clinical sleep disorders have been recognized. Certain disorders, including sleep apnea, sleep bruxism, and chronic pain, have a direct bearing on the practice of dentistry, which makes a working understanding of sleep biology (somnology) and sleep pathology (sleep medicine) a useful and necessary addition to the knowledge base of dental practitioners.
Sleep disorders decrease the quality of sleep by breaking its continuity, ie, they trigger a physiologic response that tends to push a sleeping person to a sublevel of wakefulness. Although the sleeping individual is unaware, his or her brain and autonomic nervous system are under a state of transient arousal. It is normal to observe brief arousals during sleep, but when these are too frequent or too long, they can cause mood alterations, memory problems, and performance deficits in healthy subjects after only a few days. Disordered breathing during sleep may cause serious alteration to patients’ daytime vigilance, resulting in an increased risk of transport- or work-related accidents. In the long term, sleep apnea is known to be a serious and potentially modifiable factor for cardiovascular disease, including heart failure and stroke. The intrusion of snoring and tooth-grinding sounds are also a major cause of sleep disruption for the patient’s bed partner and can be a source of marital conflict.
Orofacial pain may be associated with delayed sleep onset and disturbed sleep continuity; hence, it is a major cause of insomnia that may predispose patients to mood alteration and depression. Poor sleep is known to impair pain processing and can directly contribute to pain augmentation. Therefore, the prevention and management of sleep disorders should become a routine component of the treatment plan for chronic orofacial pain–related conditions.
Sleep medicine is often an overlooked part of public health. In many countries, access to sleep medicine constitutes a major public health challenge. In countries where therapy is available, treating sleep disturbances either as primary disorders or as comorbidities with other medical, psychiatric, or dental conditions is a significant opportunity to improve and prevent medical and psychiatric morbidity. It may also minimize the substantial financial burden related to the direct and indirect consequences of disturbed sleep. In Australia, for example, the overall cost of sleep disorders in 2004 was estimated to be US $7.5 billion with indirect costs of $808 million in related motor vehicle accidents.
The dentist plays an important role in sleep medicine by examining patients during their annual or biannual dental checkup for the risk of sleep-disordered breathing. Patients reporting snoring, sleepiness, and morning headaches in the presence of obesity, large tonsils, and/or dental malformation (eg, retrognathia, deep palate, large tongue) need to be guided by dentists to see their otorhinolaryngologist, respiratory-pulmonologist, or physician, as well as a sleep medicine expert. To manage the sound and tooth damage or pain generated by bruxism, oral appliances can be used, but the dentist needs to understand when such an appliance is indicated and the risks associated with its use. In cases where surgery is indicated, maxillofacial surgeons or otorhinolaryngologists collaborate closely with dentists to provide treatment.
When patients complain of morning headaches and temporomandibular disorders (TMDs), the exclusion of breathing disorders is a critical decision that is usually made in collaboration with the sleep medicine specialist, pulmonologist, neurologist, psychiatrist, and internal medicine physician. Dentists should refer patients who experience sleep bruxism in combination with a TMD for polysomnographic evaluation when they also complain of significant insomnia or poor sleep, even if they do not meet the traditional risk factors for sleep apnea. An increasing body of data suggests that both sleep bruxism and TMDs, which often occur in females of normal weight, are associated with increased risk for sleep disorder breathing.
Dentists caring for patients with chronic orofacial pain conditions (such as TMDs) also need to understand basic sleep hygiene principles and to know when to refer patients with chronic or intractable insomnia for behavioral sleep medicine evaluation. Behavioral treatments for chronic insomnia are considered first-line interventions over pharmacologic treatment options. A subset of chronic orofacial pain patients presents with a complex psychologic overlay that contributes to their ongoing pain and disability, a combination that can be managed by sleep psychologists working in conjunction with the interdisciplinary team.
The key aim of Sleep Medicine for Dentists is to provide a rapid source of practical information to students, practicing dentists, and scientists. Section I introduces dental sleep medicine, while sections II to IV provide an overview of how to understand, recognize, and manage sleep disorders such as sleep apnea, sleep bruxism, and orofacial pain, which often interfere with or intrude into sleep and are critically important to the practice of dentistry.
Dental sleep medicine is a rapidly evolving field of preventive medicine. However, there remains a shortage of well-trained dental sleep medicine specialists. Those learning more about this field will discover an exciting interdisciplinary arena that is rife with opportunities to develop new dental interventions to treat complex clinical situations and improve the health and well-being of the estimated 20% of the population suffering from sleep disorders.
9780867155448_lavigne_0012_001Ghizlane Aarab, DDS
Assistant Professor Oral Kinesiology
Academic Centre for Dentistry Amsterdam
University of Amsterdam
Amsterdam, The Netherlands
Florin Amzica, PhD
Professor of Stomatology
Faculty of Dental Medicine
University of Montreal
Montreal, Quebec, Canada
Taro Arima, DDS, PhD
Assistant Professor of Oral Rehabilitation
Graduate School of Dental Medicine
University of Hokkaido
Sapporo, Japan
Lene Baad-Hansen, DDS, PhD
Associate Professor of Clinical and Oral Physiology
School of Dentistry
Faculty of Health Sciences
Aarhus University
Aarhus, Denmark
Pierre J. Blanchet, MD, FRCP(C), PhD
Associate Professor of Stomatology
Faculty of Dental Medicine
University of Montreal
Neurologist
University of Montreal Hospital Centre
Montreal, Quebec, Canada
Peter R. Buchanan, MD, FRACP
Senior Clinical Research Fellow
Woolcock Institute of Medical Research
University of Sydney
Senior Staff Specialist of Respiratory Medicine
Liverpool Hospital
Sydney, New South Wales, Australia
Luis F. Buenaver, PhD, CBSM
Assistant Professor of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, Maryland
Brian E. Cairns, RPh, ACPR, PhD
Associate Professor and Canada Research Chair in Neuropharmacology
Faculty of Pharmaceutical Sciences
University of British Columbia
Vancouver, British Columbia, Canada
Claudia M. Campbell, PhD
Postdoctoral Fellow, Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, Maryland
Maria Clotilde Carra, DMD
Research Fellow, Faculty of Dental Medicine
University of Montreal
Sleep and Biological Rhythm Centre
Montreal Sacré-Coeur Hospital
Montreal, Quebec, Canada
Andrew S. L. Chan, MBBS, FRACP
Clinical and Research Fellow, Centre for Sleep Health and Research
Department of Respiratory Medicine
Royal North Shore Hospital
Woolcock Institute of Medical Research
University of Sydney
Sydney, New South Wales, Australia
Lam L. Cheng, MDSc, MOrthRCSEd, MRACDS(Ortho)
Lecturer, Discipline of Orthodontics
Faculty of Dentistry
University of Sydney
Sydney Dental Hospital
Sydney, New South Wales, Australia
Peter A. Cistulli, MBBS, PhD, MBA, FRACP
Professor of Respiratory Medicine
Head, Discipline of Sleep Medicine
University of Sydney
Research Leader, Woolcock Institute of Medical Research
Director, Centre for Sleep Health and Research
Royal North Shore Hospital
Sydney, New South Wales, Australia
François-Louis Comyn, DDS, MS
Resident of Orthodontics
School of Dental Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
M. Ali Darendeliler, PhD, BDS, CertifOrth, DipOrth, PrivDoc
Professor of Orthodontics
Faculty of Dentistry
University of Sydney
Sydney, New South Wales, Australia
Robert R. Edwards, PhD
Assistant Professor of Anesthesiology, Perioperative and Pain Medicine
Brigham & Women’s Hospital
Boston, Massachusetts
Adjunction Assistant Professor of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, Maryland
Parisa Gazerani, PharmD, PhD
Postdoctoral Fellow, Faculty of Pharmaceutical Sciences
University of British Columbia
Vancouver, British Columbia, Canada
Edward G. Grace, DDS, MA, FACD
Associate Professor of Neural and Pain Sciences
University of Maryland Dental School
Baltimore, Maryland
Ronald R. Grunstein, MD, PhD, FRACP
Professor and Head, Sleep and Circadian Group
Woolcock Institute of Medical Research
University of Sydney
Department of Respiratory and Sleep Medicine
Royal Prince Alfred Hospital
Sydney, New South Wales, Australia
Christian Guilleminault, MD, BioID
Professor, Sleep Medicine Program
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Stanford, California
Monika Haack, PhD
Instructor of Neurology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts
Raphael C. Heinzer, MD, MPH
Associate Physician, Pulmonary Department
Center for Investigation and Research in Sleep
University of Lausanne
Lausanne, Switzerland
Nelly Huynh, PhD
Postdoctoral Fellow, Sleep Medicine Program
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Stanford, California
Takafumi Kato, DDS, PhD
Associate Professor, Institute for Oral Science
Matsumoto Dental University
Chief, Dental Sleep Medicine Clinic
Matsumoto Dental University Hospital
Shiojiri, Japan
Kiyoshi Koyano, DDS, PhD
Professor and Chair of Oral Rehabilitation
Faculty of Dental Science
Kyushu University
Fukuoka, Japan
Gilles J. Lavigne, DMD, MSc, PhD, FRCD(C)
Professor of Oral Medicine and Canada Research Chair in Pain, Sleep and Trauma
Dean, Faculty of Dental Medicine
University of Montreal
Sleep and Biological Rhythm Center and Department of Surgery
Montreal Sacré-Coeur Hospital
Montreal, Quebec, Canada
Richard W. W. Lee, MBBS, FRACP
Clinical and Research Fellow, Centre for Sleep Health and Research
Department of Respiratory Medicine
Royal North Shore Hospital
Woolcock Institute of Medical Research
University of Sydney
Sydney, New South Wales, Australia
Frank Lobbezoo, DDS, PhD
Professor of Oral Kinesiology
Academic Centre for Dentistry Amsterdam
University of Amsterdam
Amsterdam, The Netherlands
Guido Macaluso, MD, DDS, MDS
Professor of Dentistry
Faculty of Medicine
University of Parma
Parma, Italy
Marie Marklund, PhD, DDS
Associate Professor of Orthodontics
Department of Odontology
Faculty of Medicine
Umeå University
Umeå, Sweden
Charles M. Morin, PhD
Professor of Psychology and Canada Research Chair in Sleep Disorders
School of Psychology
Laval University
Director, Sleep Research Center
Robert-Giffard Research Center
Quebec City, Quebec, Canada
Janet M. Mullington, PhD
Associate Professor of Neurology
Harvard Medical School
Director, Human Sleep and Chronobiology Research Unit
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Craig L. Phillips, PhD
Scientist, Department of Respiratory and Sleep Medicine
Royal North Shore Hospital
Research Fellow, Woolcock Institute of Medical Research
University of Sydney
Sydney, New South Wales, Australia
Paola Pirelli, DDS
Assistant Professor of Orthodontics
Department of Odontostomatological Sciences
Faculty of Medicine
University of Rome Tor Vergata
Rome, Italy
Richard J. Schwab, MD
Professor of Sleep Medicine
Pulmonary, Allergy and Critical Care Division
Center for Sleep and Respiratory Neurobiology
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Jennifer Scott-Sutherland, PhD
Research Fellow, Department of Anesthesiology, Perioperative and Pain Medicine
Children’s Hospital Boston
Boston, Massachusetts
Navil Sethna, MB, ChB, FAAP
Associate Professor of Anaesthesia
Harvard Medical School
Associate Director, Pain Treatment Service
Children’s Hospital Boston
Boston, Massachusetts
Michael T. Smith, PhD, CBSM
Associate Professor of Psychiatry and Behavioral Sciences
Director, Behavioral Sleep Medicine Program
Johns Hopkins University School of Medicine
Baltimore, Maryland
Peter Svensson, DDS, PhD, DrOdont
Professor and Chairman of Clinical Oral Physiology
University of Aarhus
Department of Oral and Maxillofacial Surgery
Aarhus University Hospital
Aarhus, Denmark
Nicole K. Y. Tang, DPhil
Research Fellow, Department of Psychology
Institute of Psychiatry
King’s College London
London, England
Yoshihiro Tsukiyama, DDS, PhD
Associate Professor of Oral Rehabilitation
Faculty of Dental Science
Kyushu University
Fukuoka, Japan
Henri Tuomilehto, MD, PhD
Postdoctoral Fellow, Sleep and Biological Rhythm Center
Faculty of Dental Medicine
University of Montreal
Department of Surgery
Montreal Sacré-Coeur Hospital
Montreal, Quebec, Canada
Jacques van der Zaag, DDS
Assistant Professor of Oral Kinesiology
Academic Centre for Dentistry Amsterdam
University of Amsterdam
Amsterdam, The Netherlands
Ephraim Winocur, DMD
Coordinator, Clinic for Orofacial Pain and TMD
Department of Oral Rehabilitation
The Maurice and Gabriela Goldschleger School of Dental Medicine
Tel Aviv University
Tel Aviv, Israel
Keith Wong, MBBS, PhD
Sleep Physician, Department of Respiratory and Sleep Medicine
Royal Prince Alfred Hospital
Research Fellow, Woolcock Institute of Medical Research
University of Sydney
Sydney, New South Wales, Australia
9780867155448_lavigne_0015_0019780867155448_lavigne_0016_001THE NATURE OF SLEEP
Gilles J. Lavigne, DMD, MSc, PhD, FRCD(C)
Charles M. Morin, PhD
Maria Clotilde Carra, DMD
In the animal kingdom, sleep is a universal and imperative biologic process to maintain and restore health. Sleep is defined as a physiologic and behavioral state characterized by partial isolation from the environment. A baby’s cry, the vibration of an earthquake, or a sudden pain intrusion will all interrupt sleep continuity; a sleeping brain maintains a sentinel function to awaken the organism for protection purposes.
The duration of sleep usually is 6 to 9 hours in adults. Although most adults sleep an average of 7.5 hours, some are short sleepers and some are long sleepers (ie, less than 5.5 hours and more than 9.0 hours, respectively). Good sleep quality is usually associated with a sense of having slept continuously through the night and feeling refreshed and alert on awakening in the morning. The perception of sleep quality is subjective, however, and varies widely among individuals. Some individuals perceive their sleep as satisfying most of the time, and some consistently report being poor sleepers (eg, having difficulties in initiating or maintaining sleep, feeling unrefreshed when they awaken, and having nightmares). However, sleep recording systems indicate that, in general, poor sleepers tend to underestimate the length of time they sleep (as do some good sleepers).
It is essential for dentists entering the field of dental sleep medicine to recognize sleep disorders, such as insomnia, respiratory or movement disorders (eg, snoring, obstructive sleep apnea, bruxism, gastroesophageal reflux), and pain interference. The direct and indirect costs of sleep disorders in Australia were estimated at US $7.5 billion for 2004.¹ The diagnosis, prevention, and management of sleep disorders are currently domains of high impact in public health (eg, prevention of breathing disorders from childhood, management of daytime sleepiness to decrease the risk of transportation accidents, and the relationship of hypertension and sleep apnea). An understanding of the nature of sleep is essential to the dentist’s role in management of such problems. The neurobiology of sleep is described in chapter 2, and a classification of the various sleep disorders relevant to dentistry is presented in chapter 3.
Like the management of pain, the diagnosis and management of sleep disorders are interdisciplinary. Dentists can achieve advances in sleep disorder management through collaboration with physicians (including pulmonologists, psychiatrists, neurologists, and surgeons), psychologists, respiratory therapists, and physical therapists.
Sleep and Health
Sleep entails several functions, including physical recovery, biochemical refreshment (eg, synaptic function), memory consolidation, and emotional regulation²–⁶ (Box 1-1). Lack of sleep is also known as sleep deprivation, that is, insufficient sleep resulting from short sleep duration or loss of a sleep segment because of environmental factors (eg, noise) or a contributing medical condition (eg, pain or diabetes). An experiment in young individuals comparing the consequences of sleep deprivation (4 hours of sleep over 3 to 4 days) to the effects of the subjects’ usual 8 hours of sleep showed that sleep deprivation triggers mood alteration, sociability dysfunction, and complaints of bodily pain.⁷ A persistent reduction in sleep duration can cause physical and mental health problems because of the cumulative effect of lack of sleep on several physiologic functions.
Box 1-1 Functions of sleep
Fatigue reversal
• Sleep allows the individual to recover and reenergize.
Biochemical refreshment
• Sleep promotes synaptic efficiency, protein synthesis, neurogenesis, metabolic (eg, glycogen) restoration, growth (secretion of growth hormone peaks during sleep), etc.
Immune function
• Reset or protection.
Memory
• Daytime learning needs sleep for memory consolidation.
• Sleep seems to facilitate encoding of new information.
Psychologic well-being
• Dreams occur in all sleep stages. REM dreams are more vivid.
• Lack of sleep presents a risk of mood alteration to depression.
Moreover, both too-short and too-long sleep durations have been associated with higher risks of diseases and mortality. However, the complicated interactions among lifestyle, mortality risk, and sleep duration remain to be understood.⁸ In fact, there is some evidence to support the relationship between sleep duration (too little or too much) and the risk of cardiovascular diseases (such as myocardial infarction and atherosclerosis), diabetes, obesity, depression, and even cancer.⁷–¹⁰ Although these risk estimates are modest, they have been reproduced in too many studies to reject the putative effect of cumulative sleep debt on health maintenance. Higher risks of myocardial infarction have