Sleep Medicine for Dentists:
An Evidence-Based Overview, Second Edition
To our students, patients, and research associates who have contributed to the progress in dental sleep medicine.
Library of Congress Cataloging-in-Publication Data
Names: Lavigne, Gilles J., editor. | Cistulli, Peter A., editor. | Smith, Michael T. (Michael Timothy), 1967- editor.
Title: Sleep medicine for dentists : an evidence-based overview / edited by Gilles J. Lavigne, Peter A. Cistulli, Michael T. Smith.
Description: Edition 2. | Batavia, IL : Quintessence Publishing Co, Inc, [2020] | Includes bibliographical references and index. | Summary: “This book provides a rapid source of practical information to students, practicing dentists, and scientists about the evolving field of dental sleep medicine”-- Provided by publisher.
Identifiers: LCCN 2019056811 | ISBN 9780867158281 (hardcover) | ISBN 9781647240097 (epub)
Subjects: MESH: Sleep Wake Disorders | Dentistry--methods | Mouth Diseases--complications | Tooth Diseases--complications
Classification: LCC RC547 | NLM WL 108 | DDC 616.8/4980246176--dc23
LC record available at https://lccn.loc.gov/2019056811
© 2020 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
411 N Raddant Rd
Batavia, IL 60510
www.quintpub.com
5 4 3 2 1
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.
Editorial: Bryn Grisham & Samantha Smith
Design: Sue Zubek
Production: Sue Robinson
Printed in the United States
Contents
Foreword by David Gozal
Preface
In Memoriam
Contributors
Abbreviations
Section I Introduction to Dental Sleep Medicine
1 The Nature and Structure of Sleep
Cibele Dal Fabbro, Monica L. Andersen, Gilles J. Lavigne
2 Sleep Neurobiology
Florin Amzica, Gilles J. Lavigne, Barry J. Sessle, Florian Chouchou
3 A Dental Perspective on the Classification of Sleep Disorders
Raphaël C. Heinzer, Peter A. Cistulli, Alberto Herrero Babiloni, Gilles J. Lavigne
4 Role of Dentists in Sleep Medicine
Gilles J. Lavigne, Raphaël C. Heinzer, Cibele Dal Fabbro, Michael T. Smith, Jean-François Masse, Fernanda R. Almeida, Takafumi Kato, Frank Lobbezoo, Peter A. Cistulli
Section II Sleep Breathing Disorders
5 Overview of Guidelines/Protocols for SDB
Galit Almoznino, Rafael Benoliel, Frank Lobbezoo, Luc Gauthier
6 Sleep-Related Breathing Disorders
Joseph M. Duncan, Andrew S.L. Chan, Richard W.W. Lee, Peter A. Cistulli
7 Pathophysiology of OSA
Danny J. Eckert
8 Mouth Breathing, Dentofacial Morphology, and SDB
Stacey D. Quo, Benjamin Pliska, Nelly Huynh
9 Long-Term Consequences of OSA
Frédéric Gagnadoux
10 Periodontal Diseases and OSA
Maria Clotilde Carra, Joerg Eberhard, Peter A. Cistulli
11 Clinical Approaches to Diagnosis of Adult OSA
Anna M. Mohammadieh, Richard W.W. Lee, Andrew S.L. Chan
12 Imaging in OSA
Kate Sutherland, Richard J. Schwab, Lynne E. Bilston
13 An Overview of OSA Treatment in Adults
Jesse W. Mindel, Ryan Donald, Ulysses J. Magalang
14 Diagnosis and Management of Pediatric OSA
Dimple Goel, Dominic A. Fitzgerald
15 Orofacial Orthopedic Treatment
Stacey D. Quo, Benjamin Pliska, Nelly Huynh
16 Oral Appliance Therapy
Fernanda R. Almeida, Kate Sutherland, Peter A. Cistulli
17 Upper Airway Surgical Management of OSA
Leon Kitipornchai, Stuart G. MacKay
18 Emerging Therapies for OSA
Olivier M. Vanderveken
19 Risks of Anesthesia in Patients with OSA
David R. Hillman
20 Myofunctional Therapy for OSA
Wen-Yang Li, Jean-François Masse, Frédéric Sériès
21 Precision Medicine Approaches for OSA
Kate Sutherland, Peter A. Cistulli
22 Genetics of SDB
Sutapa Mukherjee, Lyle J. Palmer
Section III Sleep Bruxism: From Oral Behavior to Disorder
23 Definitions, Epidemiology, and Etiology of SB
Frank Lobbezoo, Jari Ahlberg, Daniel A. Paesani, Ghizlane Aarab
24 Clinical Approaches to Diagnosis of SB
Kiyoshi Koyano, Yoshihiro Tsukiyama, Peter Wetselaar
25 SB as a Comorbid Condition of Other Sleep-related Disorders
Ghizlane Aarab, Ramesh Balasubramaniam, Milton Maluly Filho, Gilles J. Lavigne
26 Physiologic Mechanisms Associated with SB Genesis
Takafumi Kato, Kazuo Okura, Guido M. Macaluso, Gilles J. Lavigne
27 Psychosocial Factors in Sleep and Awake Bruxism and Other Oral Parafunctions
Richard Ohrbach, Sylvia D. Kreibig, Ambra Michelotti
28 Genetic and Environmental Factors in SB
Kazuyoshi Baba, Yuka Abe, Samar Khoury, Frank Lobbezoo
29 Consequences of SB on the Dentition, Dental Restorations, and Implants and How to Mitigate Them
Sandro Palla, Iven Klineberg, Mauro Farella
30 Behavioral, Dental, Pharmacologic, and Alternative Management of SB
Daniele Manfredini, Charles R. Carlson, Ephraim Winocur, Frank Lobbezoo
31 SB in Children and Adolescents
Nelly Huynh, Naomi Kadoch, Christian Guilleminault
Section IV Sleep and Orofacial Pain
32 Definition and Classification of Orofacial Pains
Alberto Herrero Babiloni, Donald R. Nixdorf
33 Pathophysiologic Conceptualizations of the Transition from Acute to Chronic Pain
Claudia M. Campbell, Robert R. Edwards, Janelle E. Letzen
34 Mechanisms Underlying the Interactions Between Sleep Deficiency and Pain
Monika Haack, Navil Sethna
35 Behavioral and Pharmacologic Approaches to Manage Chronic Pain Comorbid with Sleep Disturbances
Monika Haack, Navil Sethna
36 Association and Putative Causality of Orofacial Pain Conditions and Sleep Disturbances
Peter Svensson, Lene Baad-Hansen, Taro Arima, Antoon De Laat
37 Sleep and Headache
Scott Maddalo, Shuja Rayaz, Michael T. Smith, Nauman Tariq
38 Pharmacologic Management of Sleep-Pain Interactions
Traci J. Speed
39 The Use and Risks of Opioids in the Management of Orofacial Pain
Alberto Herrero Babiloni, Léa Proulx-Bégin, Gilles J. Lavigne, Marc O. Martel
40 Nonpharmacologic Management of Insomnia and Orofacial Pain
Daniel Whibley, Nicole K.Y. Tang, Michael T. Smith
Index
Foreword
It is quite unbelievable that more than 10 years have elapsed since the first edition of Sleep Medicine for Dentists appeared! At that time, it seemed almost daring to publish a book on sleep disorders aimed at the dental profession. Yet, there is little doubt now that dentists are one of the many important portals of entry through which patients can gain earlier detection and therefore benefit from improved management of sleep disorders. Furthermore, the array of uniquely valuable and efficacious tools that dentists bring to the field is further enhanced by the fact that increased knowledge of sleep among any health care professional and by the public at large can only lead to better outcomes.
We cannot forget, or for that matter let anyone else forget, that sleep is a vital function and constitutes the fourth pillar of health and wellness. As such, rather than continue the isolationist route of silo building across professions and disciplines, focusing only on our area of expertise, there has been a slow and steady progressive evolution toward multidisciplinary and interdisciplinary cooperation in sleep medicine. Are we there yet? No, not yet, but we are moving in the right direction, and to continue getting there, we need to make sure that all health care professionals receive adequate and informative training focused around sleep and its disorders.
Before I comment on how this new edition of the book elegantly achieves such lofty goals, I want to remind ourselves that we tend to forget large portions of the wisdom generated by our predecessors. I was recently pointed to a paper published in 1913 by The Boston Medical and Surgical Journal (now The New England Journal of Medicine). In this short manuscript, Dr Irving Sobotky was already challenging the effectiveness of adenotonsillectomy in children and remarked on the high frequency of patients who continued to be mouth breathers despite “successful” surgeries.1 He further elaborated on the importance of nasal breathing. More than 100 years after this observation, we are still in pursuit of the elusive ideal of nasal breathing. Hopefully, this time, we can count on not only ENTs and sleep physicians but on the many other disciplines, and top among them, dentists, to help our patients breathe well through their noses.
As a sleep physician who has been deeply involved in sleep medicine over 30 years, I am thrilled to see the uniquely exquisite attention and effort paid in this new edition to facilitate learning and attract learners. The content is carefully divided and balanced between important areas of sleep that are pertinent to the dental profession, and the inordinately attractive and visually pleasing layout of text, tables, and graphics makes it nearly impossible to let go of the book once you get started. I would definitely hope that this textbook will become a mandatory part of the curriculum for all dental schools, and that it will stimulate many of its readers to not only put the knowledge gained to practice but also go and dig deeper and bring their ingenuity to the forefront, thereby advancing the field.
David Gozal, MD, MBA
Marie M. and Harry L. Smith Endowed Chair
Chairperson and Pediatrician-in-Chief
Department of Child Health
MU Women’s and Children’s Hospital
University of Missouri School of Medicine
Columbia, Missouri
1. Sobotky I. Persistent mouth breathing following adenoidectomies. Boston Med Surg J 1913;168:230–231.
Preface
It has been 11 years since the publication of the first edition of this dental sleep medicine book with Quintessence. The key aim of Sleep Medicine for Dentists was to provide a rapid source of practical information to students, practicing dentists, and scientists about the evolving field of dental sleep medicine. We sought to put a stake in the ground to herald the emergence of a new interdisciplinary field. The first edition was an instant success, with such strong continued interest that in the last few years the book has only been available for resale by a previous owner. This is a strong indication that the field of dental sleep medicine is growing in both the clinical practice and academic spheres. The book became an academic and board exam reference—a testament to its stature as an authoritative but concise resource. We thank everyone who believed in our collective work.
The role of dentistry in sleep medicine has evolved considerably over the last decade and is now accepted as an important component of the multidisciplinary approach to diagnosis and management of patients with diverse sleep complaints across the lifespan. There is a critical role for dentistry from childhood upper airway and oral development to management of adult sleep apnea, diagnosis of oral conditions linked to sleep-disordered breathing, sleep bruxism, and orofacial pain syndromes. What was previously considered the exclusive domain of the medical profession has now expanded to other disciplines, including dentistry, psychology, and physical/speech therapy. Dentists, dental therapists, and hygienists are among a team of collaborators that are increasingly and, sometimes uniquely, well-positioned in health care systems to maintain quality of life and optimal health for patients suffering with sleep-related breathing disorders, sleep bruxism, orofacial pain, and other orofacial-related syndromes that disrupt sleep and exacerbate pain and fatigue. The role of concomitant conditions (ie, comorbidities) with the above three major sleep problems is also of critical concern.
We believe the timing of this second edition is a perfect way to highlight the incredible advancements that have occurred in the last decade to entrench the role of dentistry in sleep medicine. The 2020 edition has been expanded from 24 to 40 chapters. As before, the book has 4 sections: Introduction to Dental Sleep Medicine, Sleep Breathing Disorders, Sleep Bruxism: From Oral Behavior to Disorder, and Sleep and Orofacial Pain. All previous chapters were updated, and new ones have been added based on the suggestions of many of our readers. The objective of this new edition is to present evidence-based material in a practical manner to guide students in their training and clinicians in their practice.
Editing such a book would have been impossible without the collective, respectful, and professional effort of the three editors, and our colleague Frank Lobbezoo, who provided invaluable input on the sleep bruxism section. We owe our gratitude to all authors and coauthors for their generosity of time, commitment, and integrity. They have come together to share with you the best of their knowledge and their passion for dental sleep medicine. We also want to thank Bryn Grisham and Samantha Smith from Quintessence for their perseverance in working on the second edition of the book.
In Memoriam
Christian Guilleminault (1938–2019)
This book is dedicated to Doctor Christian Guilleminault, who was a faithful advocate for the role and importance of dental sleep medicine.
Contributors
Ghizlane Aarab, DDS, PhD
Associate Professor
Department of Orofacial Pain and Dysfunction
Academic Centre for Dentistry Amsterdam (ACTA)
University of Amsterdam and Vrije Universiteit Amsterdam
Amsterdam, Netherlands
Yuka Abe, DDS, PhD
Assistant Professor
Department of Prosthodontics
Showa University
Tokyo, Japan
Jari Ahlberg, DDS, PhD
Associate Professor
Department of Oral and Maxillofacial Diseases
University of Helsinki
Helsinki, Finland
Fernanda R. Almeida, DDS, PhD
Associate Professor
Department of Oral Health Science
Faculty of Dentistry
University of British Columbia
Vancouver, British Columbia
Galit Almoznino, DMD, MSc, MHA
Senior Lecturer and Head
Big Biomedical Data Research Laboratory
Orofacial Sensory Clinic
Taste and Smell Clinic
Department of Oral Medicine Sedation & Maxillofacial Imaging
Hebrew University Hadassah School of Dental Medicine
Jerusalem, Israel
Florin Amzica, PhD
Professor
Departments of Stomatology and Neuroscience
Faculties of Dentistry and Medicine
Université de Montréal
Montréal, Québec
Monica L. Andersen, PhD
Associate Professor and Vice-Chair
Department of Psychobiology
Escola Paulista de Medicina
Universidade Federal de São Paulo
São Paulo, Brazil
Taro Arima, DDS, PhD
Associate Professor
Faculty of Dental Medicine
Hokkaido University
Sapporo, Japan
Lene Baad-Hansen, DDS, PhD, Dr Odont
Associate Professor and Deputy Department Head
Department of Dentistry and Oral Health
Aarhus University
Aarhus, Denmark
Kazuyoshi Baba, DDS, PhD
Professor and Chair
Department of Prosthodontics
Showa University
Director
Showa University Dental Hospital
Tokyo, Japan
Ramesh Balasubramaniam, BDSc, MS, MRACDS (OralMed), FOMAA
Clinical Associate Professor
Faculty of Health and Medical Sciences
University of Western Australia Dental School,
Perth, Australia
Rafael Benoliel, BDS, LDS, RCS
Professor and Associate Dean for Research
Director
Center for Orofacial Pain and TMDs
Rutgers School of Dental Medicine
State University of New Jersey
Newark, New Jersey
Lynne E. Bilston, PhD
Senior Principal Research Fellow
Neuroscience Research Australia
Conjoint Professor in Medicine
University of New South Wales
Sydney, Australia
Claudia M. Campbell, PhD
Associate Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, Maryland
Charles R. Carlson, PhD
Professor
Department of Psychology and Oral Health Practice
University of Kentucky
Lexington, Kentucky
Maria Clotilde Carra, DDS, MSc, PhD
Associate Professor
Department of Periodontology
Rothschild Hospital
Paris, France
Faculty of Odontology
University of Paris
Paris, France
Andrew S. L. Chan, MBBS, PGCertClinLds, MBA, PhD, FRACP
Deputy Director
Centre for Sleep Health and Research
Department of Respiratory and Sleep Medicine
Royal North Shore Hospital
Clinical Associate Professor
The University of Sydney School of Medicine
Sydney, Australia
Florian Chouchou, PhD
Assistant Professor
Department of Physical Activity and Sports Science
University of La Réunion
La Réunion, France
Peter A. Cistulli, MD, PhD, MBA, FRACP, FCCP, ATSF
Professor
ResMed Chair in Sleep Medicine
Charles Perkins Centre
Faculty of Medicine and Health
University of Sydney
Director of the Centre for Sleep Health and Research
Department of Respiratory and Sleep Medicine
Royal North Shore Hospital
Sydney, Australia
Cibele Dal Fabbro, DDS, MSc, PhD
Clinician
Instituto do Sono
Visiting Research Scientist
Center for Advanced Research in Sleep Medicine
Sacred Heart Hospital of Montréal
Montréal, Québec
Antoon De Laat, DDs, PhD
Professor
Department of Oral Health Sciences
Catholic University of Leuven
Leuven, Belgium
Ryan Donald, MD
Assistant Professor
Division of Pulmonary, Critical Care, and Sleep Medicine
Department of Medicine
The Ohio State University Wexner Medical Center
Columbus, Ohio
Joseph M. Duncan, MBBS
Sleep Fellow
Department of Respiratory and Sleep Medicine
Royal North Shore Hospital
Sydney, Australia
Joerg Eberhard, Dr med dent, MME
Chair of Lifespan Oral Health
Charles Perkins Centre
University of Sydney School of Dentistry
University of Sydney
Sydney, Australia
Danny J. Eckert, PhD
Professor
College of Medicine and Public Health
Director
Adelaide Institute for Sleep Health
Flinders University
Bedford Park, Australia
Robert R. Edwards, PhD
Associate Professor of Anesthesia
Pain Management Center
Brigham and Women’s Hospital
Harvard Medical School
Boston, Massachusetts
Mauro Farella, DDS, PhD
Professor and Chair
Discipline of Orthodontics
Department of Oral Sciences
Sir John Walsh Research Institute
University of Otago
Dunedin, New Zealand
Milton Maluly Filho, DDS, PhD
Postdoctoral Fellow
Division of Sleep Medicine and Biology
Department of Psychobiology
Paulista School of Medicine
Federal University of São Paulo
São Paulo, Brazil
Dominic A. Fitzgerald, MBBS, PhD, FRACP
Pediatric Respiratory Sleep Physician and Professor
Discipline of Child & Adolescent Health
Department of Respiratory Medicine
The Children’s Hospital at Westmead
Sydney Medical School
University of Sydney
Sydney, Australia
Frédéric Gagnadoux, MD, PhD
Professor
Department of Respiratory and Sleep Medicine
Angers University Hospital
Angers, France
Luc Gauthier, DMD, MSc
Visiting Professor
Faculty of Dentistry
Université de Montréal
Montréal, Québec
Dimple Goel, MBBS, MD, FRACP
Pediatric Sleep Fellow
Department of Respiratory Medicine
The Children’s Hospital at Westmead
Conjoint Associate Lecturer
Pediatric and Child Health Division
University of Sydney
Sydney, Australia
Christian Guilleminault,* MD, DM, DBiol
Professor
Sleep Medicine Program
Department of Psychiatry and Behavioral Sciences
Stanford University School of Medicine
Redwood City, California
Monika Haack, MA, PhD
Associate Professor
Department of Neurology
Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, MA
Raphaël C. Heinzer, MD-MPH
Associate Professor and Head
Center for Investigation and Research in Sleep
Lausanne University Hospital
Lausanne, Switzerland
*Deceased
Alberto Herrero Babiloni, DDS, MS
PhD Student
Center for Advanced Research in Sleep Medicine
Sacred Heart Hospital of Montréal
Université de Montréal
Division of Experimental Medicine
McGill University
Montréal, Québec
David R. Hillman, AM, MBBS, FANZCA, FRCP, FRACP (hon)
Clinical Professor and Senior Principal
Research Fellow
Department of Pulmonary Physiology and Sleep Medicine
Sir Charles Gairdner Hospital
Centre for Sleep Science
University of Western Australia
Perth, Australia
Nelly Huynh, PhD
Associate Professor
Faculty of Dentistry
CHU Sainte-Justine Research Center
Université de Montréal
Montréal, Québec
Naomi Kadoch, DMD
Research Student
Faculty of Dentistry
Université de Montréal
Montréal, Québec
Takafumi Kato, DDS, PhD
Professor
Department of Oral Physiology
Graduate School of Dentistry
United Graduate School of Child Development
Osaka University
Sleep Medicine Center
Osaka University Medical Hospital
Osaka, Japan
Samar Khoury, PhD
Postdoctoral Fellow
Alan Edwards Center for Research on Pain
McGill University
Montréal, Québec
Leon Kitipornchai, BEng, MBBS, MEpi, FRACS
Clinical Senior Lecturer
School of Clinical Medicine
University of Queensland
Brisbane, Australia
Iven Klineberg, AM, RFD, BSc, MDS, PhD, FDSRCS, FICD
Emeritus Professor of Prosthodontics
School of Dentistry
Faculty of Medicine and Health
Westmead Hospital Centre for Oral Health
University of Sydney
Sydney, Australia
Kiyoshi Koyano, DDS, PhD
Professor
Division of Oral Rehabilitation
Faculty of Dental Science
Kyushu University
Fukoka, Japan
Sylvia D. Kreibig, PhD
Senior Research Scientist
Department of Psychology
Stanford University
Stanford, California
Gilles J. Lavigne, DMD, PhD, FRCD(c), hc, FACD, FCAHS, OC (CM)
Professor
Canada Research Chair on Pain, Sleep, and Trauma
Faculty of Dental Medicine
Université de Montréal
Clinical Research Scientist
Center for Advanced Research in Sleep and Trauma Unit
Sacred Heart Hospital (CIUSSS North Island)
Montréal, Québec
Richard W. W. Lee, MBBS, PhD, FRACP
Codirector
Sleep Investigation Unit
Department of Respiratory Medicine
Gosford Hospital
Conjoint Senior Lecturer
School of Medicine and Public Health
University of Newcastle
New South Wales, Australia
Janelle E. Letzen, PhD
Postdoctoral Research Fellow
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, Maryland
Wen-Yang Li, MD, PhD
Lecturer
Respiratory and Critical Care Department
First Hospital of China Medical University
Shen Yang City, China
Frank Lobbezoo, DDS, PhD
Professor, Chair, and Vice-Dean
Department of Orofacial Pain and Dysfunction
Academic Centre for Dentistry Amsterdam (ACTA)
University of Amsterdam and Vrije Universiteit Amsterdam
Amsterdam, The Netherlands
Guido M. Macaluso, MD, DDS, MDS
Director
Center of Dental Medicine
Dean
Department of Medicine and Surgery
School of Dentistry
University of Parma
Parma, Italy
Stuart G. MacKay, BSc (Med), MBBS (Hons), FRACS
Honorary Clinical Professor
Otolaryngology and Head and Neck Surgery
University of Wollongong Graduate School of Medicine and Illawarra Shoalhaven Local Health District
Wollongong, Australia
Scott Maddalo, MD, MS
Pain Management Specialist
Department of Anesthesiology
St John’s Riverside Hospital
Hawthorne, New York
Ulysses J. Magalang, MD
Professor
Neuroscience Research Institute
Division of Pulmonary, Critical Care, and Sleep Medicine
Department of Medicine
The Ohio State University Wexner Medical Center
Columbus, Ohio
Daniele Manfredini, DDS, PhD
Professor
School of Dentistry
Department of Biomedical Technologies
University of Siena
Siena, Italy
Marc O. Martel, PhD
Assistant Professor
Faculty of Dentistry and Department of Anesthesia
McGill University
Montréal, Québec
Jean-François Masse, DMD, MSc
Visiting Professor
Faculty of Dentistry
Laval University
Québec City, Québec
Ambra Michelotti, BSc, DDS
Professor
Department of Neurosciences, Reproductive Sciences and Oral Sciences
Division of Orthodontics
University of Naples Federico II
Naples, Italy
Jesse W. Mindel, MD
Assistant Professor of Neurology and Internal Medicine
Department of Neurology
Department of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine
The Ohio State University Wexner Medical Center
Columbus, Ohio
Anna M. Mohammadieh, BA, MBBS, FRACP
Respiratory and Sleep Physician
Centre for Sleep Health and Research
Department of Respiratory Medicine
Royal North Shore Hospital
Charles Perkins Centre
University of Sydney
Sydney, Australia
Department of Thoracic Medicine
St Vincent’s Hospital
Darlinghurst, Australia
Sutapa Mukherjee, MBBS, PhD
Associate Professor
Sleep Health Service
Respiratory and Sleep Services
Southern Adelaide Local Health Network
Adelaide Institute for Sleep Health
Flinders University
Adelaide, Australia
Donald R. Nixdorf, DDS, MS
Professor and Director
Division of TMD/Orofacial Pain
School of Dentistry
University of Minnesota
Minneapolis, Minnesota
Department of Neurology
Medical School
University of Minnesota
Minneapolis, Minnesota
Richard Ohrbach, DDS, PhD
Professor
Department of Oral Diagnostic Sciences
University at Buffalo School of Dental Medicine
Buffalo, New York
Kazuo Okura, DDS, PhD
Lecturer
Department of Stomatognathic Function and Occlusal Reconstruction
Institute of Biomedical Sciences
Tokushima University Graduate School
Tokushima, Japan
Daniel A. Paesani, DDS
Professor of Stomathognatic Physiology
University of Salvador
Buenos Aires, Argentina
Sandro Palla, Dr med dent
Emeritus Professor
Center for Dentistry
University of Zürich
Zürich, Switzerland
Lyle J. Palmer, PhD
Professor of Genetic Epidemiology
School of Public Health
University of Adelaide
Adelaide, Australia
Benjamin Pliska, DDS, MS
Associate Professor
Division of Orthodontics
Faculty of Dentistry
University of British Columbia
Vancouver, British Columbia
Léa Proulx-Bégin, BA
Doctoral Candidate
Department of Psychology
Université de Montréal
Montréal, Québec
Stacey D. Quo, DDS, MS
Clinical Professor
Department of Orofacial Sciences
School of Dentistry
University of California
San Francisco, California
Shuja Rayaz, MD
Resident
Department of Medicine
Mercy Hospital
Baltimore, Maryland
Richard J. Schwab, MD
Professor
Center for Sleep and Circadian Neurobiology
Perelman School of Medicine
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Frédéric Sériès, MD
Professor
Centre de pneumologie
Québec Cardiology and Respirology University Institute
Laval University
Québec City, Québec
Barry J. Sessle, MDS, PhD, FRSC
Professor
Faculty of Dentistry and Medicine
Department of Physiology
University of Toronto
Toronto, Ontario
Navil Sethna, MBchB
Clinical Director of the Pediatric Pain Rehabilitation Center
Senior Associate in Perioperative Anesthesia
Department of Anesthesiology, Critical Care, and Pain Medicine
Boston Children’s Hospital
Boston, Massachusetts
Associate Professor in Anesthesiology
Harvard Medical School
Cambridge, Massachusetts
Michael T. Smith, PhD, DBSM
Professor of Psychiatry and Behavioral Sciences
Professor of Neurology
Director, Division of Behavioral Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
Traci J. Speed, MD, PhD
Assistant Professor
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine
Baltimore, MD
Kate Sutherland, PhD
Research Fellow
Sleep Group
Charles Perkins Centre
Faculty of Medicine and Health
University of Sydney School of Medicine
Centre for Sleep Health and Research
Department of Respiratory Medicine
Royal North Shore Hospital
Sydney, Australia
Peter Svensson, DDS, PhD, DrOdont
Professor and Head
Section of Orofacial Pain and Jaw Function
Department of Dentistry and Oral Health
Faculty of Health
Aarhus University
Aarhus, Denmark
Nicole K.Y. Tang, DPhil CPsychol
Reader
Department of Psychology
University of Warwick
Coventry, United Kingdom
Nauman Tariq, MBBS
Assistant Professor of Neurology
Director, Headache Center
Johns Hopkins School of Medicine
Baltimore, MD
Yoshihiro Tsukiyama, DDS, PhD
Professor
Section of Dental Education
Division of Oral Biological Sciences
Faculty of Dental Science
Kyushu University
Fukuoka, Japan
Olivier M. Vanderveken, MD, PhD
Professor and Chairman of Ear, Nose, Throat, Head, and Neck Surgery Deparment
Antwerp University Hospital
University of Antwerp
Antwerp, Belgium
Peter Wetselaar, DDS, MSc, PhD
Associate Professor
Department of Oral Kinesiology
Head
Clinic of Orofacial Pain and Dysfunction
Program Director
Oral Health Sciences
Academic Centre for Dentistry Amsterdam (ACTA)
University of Amsterdam and Vrije Universiteit Amsterdam
Amsterdam, The Netherlands
Daniel Whibley, PhD
Epidemiology Group
School of Medicine. Medical Sciences, and Nutrition
University of Aberdeen,
Aberdeen, United Kingdom
Ephraim Winocur, DMD
Clinical Assistant Professor
Department of Oral Rehabilitation
The Maurice and Gabriela Goldschleger School of Dental Medicine
Sackler Faculty of Medicine
Tel Aviv University
Tel Aviv, Israel
Abbreviations
This reference list contains the most common abbreviations used throughout the book. Please note that these terms will not be spelled out in the book.
AHI | Apnea-Hypopnea Index |
BMI | body mass index |
CBCT | cone beam computed tomography |
CPAP | continuous positive airway pressure |
CSA | central sleep apnea |
CT | computed tomography |
DSM | dental sleep medicine |
EDS | excessive daytime sleepiness |
ENT | ear, nose, and throat specialist/surgeon |
ESS | Epworth Sleepiness Scale |
MAD | mandibular advancement device |
MRI | magnetic resonance imaging |
NREM | non-REM |
OA | oral appliance |
OAT | oral appliance therapy |
OSA | obstructive sleep apnea |
PAP | positive airway pressure |
PCRIT | pharyngeal upper airway collapsibility |
PLMD | periodic limb movement disorder |
PSG | polysomnography/polysomnogram |
RBD | REM behavior disorders |
REM | rapid eye movement |
SB | sleep bruxism |
SDB | sleep-disordered breathing |
SRBD | sleep-related breathing disorder |
TMD | temporomandibular disorder |
CHAPTER 1
The Nature and Structure of Sleep
Cibele Dal Fabbro
Monica L. Andersen
Gilles J. Lavigne
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 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—insomnia, 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). The neurobiology of sleep is described in chapter 2, and a classification of the various sleep disorders relevant to dentistry is found in chapter 3.
Sleep-Wake Cycle
An adult’s 24-hour cycle is divided into approximately 16 hours of wakefulness and 8 hours of sleep. Synchronization and equilibrium between the sleep-wake cycle and feeding behaviors are essential for survival. Mismatches in the synchronization of the feeding cue and metabolic activity are associated with eating disorders.1 Poor sleep can cause health problems and can increase the risk of transportation- and work-related accidents and even death.2
Homeostatic process
The propensity to sleep is directly dependent on the duration of the prior wakefulness episode. As the duration of wakefulness increases, sleep pressure accumulates and builds to a critical point, when sleep onset is reached. As this sleep pressure increases, an alerting circadian signal helps the person to remain awake throughout the day. The ongoing 24-hour circadian rhythm therefore runs parallel to the homeostasis process, also known as process S (Fig 1-1). The process S corresponds to the sleep pressure that individuals accumulate during the wakefulness period before being able to fall asleep. With increasing sleep pressure, sleep is proportionally longer and deeper in the following recovery period.
Changes in the frequency of slow-wave sleep waves can be estimated by a mathematic transformation of brain wave electrical signals or by quantitative spectral analysis of the electroencephalographic (EEG) activity. Rising or rebound of slow-wave EEG activity in the first hours of sleep is a marker of sleep debt.3 In contrast, a reduction in slow-wave activity is observed in patients with chronic pain.4,5 However, the cause-and-effect association of these biologic signals with reports of fatigue and poor sleep is unknown. During the day, the effects of energy expenditure are accumulated, which may be connected to the feeling of tiredness.
Two times in the 24-hour cycle are characterized by a strong sleep pressure, 4 PM and 4 AM, +/- 1 to 2 hours (see Fig 1-1). At a certain point, sleep pressure is so powerful that an individual will fall asleep regardless of the method or strategies used to remain awake.
Circadian rhythm
Humans tend to alternate between a period of wakefulness lasting approximately 16 hours and a continuous block of 8 hours of sleep (see Fig 1-1). Most mammals sleep around a 24-hour cycle that is driven by clock genes that control the circadian rhythm (process C). Light helps humans synchronize their rhythm with the cycles of the sun and moon by sending a retinal signal (melanopsin) to the hypothalamic suprachiasmatic nucleus. The suprachiasmatic nucleus is a network of brain cells and genes that acts as a pacemaker to control the circadian timing function.6
The investigation of sleep-wake process C uses biologic markers to assess a given individual’s rhythm. A slight drop (hundredths of a degree centigrade) in body temperature and a rise in salivary and blood melatonin and growth hormone release—peaking in the first hours of sleep, around midnight in the 24-hour cycle—are key indications of the acrophase (high peak) of the process C. Interestingly, corticotropins (adrenocorticotropic hormone and cortisol) reach a nadir (lowest level) during the first hour of sleep. They then reach an acrophase in the second half of the night.1,7 The process C can also be studied using temperature recordings in relation to hormone release and polygraphy to measure brain, muscle, and heart activities.
Ultradian rhythm
Under the 24-hour process C of sleep and wakefulness, sleep onset and maintenance are governed by an ultradian cycle of three to five periods in which the brain, muscles, and autonomic cardiac and respiratory activities fluctuate (Figs 1-2 and 1-3).8 These cycles consist of REM sleep (active stage) and NREM sleep (light and deep stages). The REM stage is known as paradoxical sleep in some countries.
In humans, a clear decline in electrical brain and muscle activities as well as heart rhythm is observed from wakefulness to sleep onset. This decline is associated with a synchronization of brain waves toward stage N1 of sleep. Stage N1 is a transitional period between wakefulness and sleep. Stage N2, which accounts for about 50% to 60% of total sleep duration, is characterized by two EEG signals—K-complexes (brief, high-amplitude brain waves) and spindles (rapid, spring-like EEG waves)—both described as sleep-promoting and sleep-preserving factors. Sleep N1 and N2 are categorized as light sleep.
Next, sleep enters a quiet period known as deep sleep, or stage N3, which is characterized by slow, high-amplitude brain wave activities, with dominance of delta sleep (0.5 to 4.5 Hz). This sleep period is associated with a so-called sleep recovery process.
Finally, sleep enters an ascension period and rapidly turns into either light sleep or REM sleep. REM sleep is associated with a reduction in the tone of postural muscles (which is poorly described as “atonia” in literature but is in fact hypotonia because muscle tone is never zero; see chapter 2, reference 13) and a rise in heart rate and brain activity to levels that frequently surpass the rates observed during wakefulness.
Humans can dream in all stages of sleep, but dreams during REM sleep may involve intensely vivid imagery with fantastic and creative content. During REM sleep, the body is typically in a paralyzed-like state (muscle hypotonia). Otherwise, dreams with intense emotional content and motor activity might cause body movements that could injure individuals and their sleep partners.
An understanding of the presence of ultradian sleep cycles is relevant because certain pathologic events occur during sleep, including the following sleep disorders:
• Periodic body movements (leg or arm) and jaw movements, such as SB, most of which are observed in stage N2 of sleep and with less frequency in REM sleep
• Sleep-related breathing events, such as apnea and hypopnea (cessation or reduction of breathing), observed in N2 and REM sleep
• Acted dreams with risk of body injury, diagnosed as RBD, which occur during REM sleep (see chapter 3)
Sleep Recordings and Sleep Arousal
When a PSG of a sleeping patient (collected either at home with an ambulatory system or in a sleep laboratory) is assessed, the scoring of sleep fragmentation is a key element in analyzing sleep quality. Poor sleep quality, as reported subjectively by the patient, is associated on PSGs with more bed time with wake after sleep onset (WASO), frequent arousals with or without body movements or with a high score of periodic limb movement (PLM), frequent stage shifts (from a deeper to a lighter sleep stage), respiratory disturbances (measured per hour by the respiratory disturbance index [RDI]), and higher muscle tone. All these signs of sleep fragmentation interrupt the continuity of sleep and alter the sleep architecture.
Sleep efficiency is another important variable to evaluate. A standard index of sleep impairment, sleep efficiency is defined as the amount of time asleep divided by the amount of time spent in bed, expressed as a percentage. Sleep efficiency greater than 90% is an indicator of good sleep.
The ultradian cycle of sleep, described previously, includes another repetitive activity: sleep-related arousals. During NREM sleep, arousals are recurrent (6 to 14 times per hour of sleep), involving brief (3 to 10 seconds) awakenings associated with increased brain, muscle, and heart activities (tachycardia or rapid heart rate) in the absence of the return of consciousness.9–11 In the presence of sleep movements, breathing disorders, or chronic pain, these arousals are more frequent. Sleep arousals can be viewed as the body’s attempt to prepare the sleeping individual (who is in a low-vigilance state) to react to a potential risk, ie, a fight-or-flight state.
Sleep arousals are concomitant with or precede most PLMs and SB (described also in chapter 26 on pathophysiology of SB, section III). In contrast, sleep apnea and hypopnea (described in section II) are respiratory distress–like events that trigger sleep arousals. An index of arousal per hour of sleep is estimated as well as arousal-related ones: frequency of shifts in sleep stage, PLMs, bruxism, snoring, and sleep-related apnea and hypopnea.
In addition to these methods, sleep fragmentation can be estimated by the presence of the cyclic alternating pattern (CAP) to evaluate the instability of sleep. CAP is an infraslow oscillation, with a periodicity of 20 to 40 seconds, between the sleep maintenance system and the arousal pressure involved in the dynamic organization of NREM sleep and the activation of motor events.12
CAP is the estimate of the dominance of active phasic arousal periods—that is, the rise in heart rate, muscle tone, and EEG activities (phase A)—over more stable and quiet sleep periods (phase B).11,13 The active phase is subclassified as A1, a period that promotes sleep onset and maintenance; A2, a transition phase; and A3, the final phase, or the arousal window, involving a marked increase in muscle tone and cardiorespiratory rate. Note that most SB events are scored in phases A2 and A3 (see chapter 26).
People appear to have individual levels of tolerance for sleep fragmentation. These levels may be genetically determined. Nevertheless, recurrent sleep deprivation or fragmentation produces a cumulative sleep debt, which in turn is likely to increase complaints of fatigue, memory and mood dysfunction, and bodily pain. The cause-and-effect relationship remains to be supported by evidence.
Developmental Changes in Sleep-Wake Patterns
The human sleep-wake pattern changes with biologic maturation and aging. In the first 6 weeks of life, sleep of infants is dominated by REM sleep, which occupies about 50% of their sleep time. Around age 6 to 9 months, their wakefulness and nighttime sleep pattern tends to become more synchronized with their parents’ feeding and sleeping schedule.14 Preschool children sleep about 14 hours per 24-hour cycle, and most stop napping somewhere between the ages of 3 and 5 years. An important aspect related to development is the growth of the airway and involution of adenoids that seems to influence occurrence and resolution of snoring and apnea in children between 5 to 12 years of age (see chapter 14).
Pre-adolescent children are sleep-wake phase advanced. They fall asleep earlier and awake earlier than middle-aged adults. Teenagers tend to be phase delayed (get to bed later and wake later in morning) and tend to sleep about 9 hours per 24 hours (ranging from 6.5 to 9.5 hours), falling asleep and awakening later than their parents and younger siblings.
Most adults sleep about 6 to 7 hours on workdays and more on the weekends. By about the age of 40 to 45 years, adults’ sleep starts to become more fragile, and individuals are more aware of being awake for a few seconds to a few minutes a night. In the elderly, the sleep-wake pattern returns to a multiphase pattern typical of young children. Elderly people go to sleep earlier than middle-aged adults and awake earlier in the morning, taking occasional naps (catnapping) during the day. Some may present advanced phase shift, ie, get to sleep earlier and wake earlier in morning.
The human biologic clock can adapt to sleep deprivation and changes in the sleep-wake schedule within certain limits. For example, some people can adapt better than others to jetlag or sleep deprivation because of night work (eg, flight crew, hospital staff), but most individuals find such variations difficult.
Sleep and Health
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).
Sleep and circadian rhythm entail several functions, including physical recovery, biochemical refreshment (eg, synaptic neuronal function; glial cell role in glymphatic process), memory consolidation, emotional regulation, and to a small extent, possible learning of simple tasks/behaviors15–22 (Box 1-1). 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 (see chapters 9 and 33 to 35).
BOX 1-1 Functions of sleep
Fatigue reversal
• Sleep allows the individual to recover and reenergize.
Biochemical refreshment
• Sleep promotes synaptic efficiency, glymphatic lavage, protein synthesis, neurogenesis, metabolic (eg, glycogen) restoration, growth (secretion of growth hormone peaks during sleep), etc.
Immune function
• Reset or protection (complex interaction; causality under investigation).
Memory consolidation
• Daytime learning needs sleep for memory consolidation.
• Sleep seems to facilitate encoding of new information.
• May also facilitate learning of simple tasks, modify behavior.
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.