Dental health and sleep issues are known to be related; however, the number of diseases that are intertwined and their associated causes and treatments may be unclear, making collaboration key between specialties. “Doctors and dentists now recognize that sleep, breathing, and dental health are deeply connected,” said Rupali Drewek, MD, pediatric co-medical director of the sleep medicine program at Phoenix Children’s Hospital in Phoenix.

“People who sleep poorly or have obstructive sleep apnea (OSA) often breathe through their mouth at night, which dries out saliva — a natural defense against cavities and infection. Reduced saliva increases the risk of tooth decay, gum disease, and sensitivity. Poor sleep also raises stress hormones and systemic inflammation, weakening the immune system in the gums and making gingivitis and periodontal disease more likely. Sleep disorders are also linked to changes in the oral microbiome, favoring bacteria that contribute to cavities and gum disease.”

At the same time, orthodontia-related ailments such as bruxism, or teeth grinding, can bring about changes to jaw structure and result in sleep disorders, not to mention joint pain and headaches. And because dental and airway health influence each other, dental findings can be early clues to sleep problems, Drewek explained. “Treating the airway can improve both sleep and dental outcomes.”

As research on the combined impacts of these maladies has become more enlightening, care collaboration for patients of all ages among sleep and dental professionals has improved over time, according to Drewek and other providers. Utilization of sleep-related interventions such as continuous positive airway pressure (CPAP) and oral appliance therapy (OAT), such as mandibular advancement devices and tongue-stabilizing devices, are proving to be beneficial when introduced separately or together, depending on individual diagnosis and care planning.

“The connection between sleep and dental health works in both directions, which is why collaboration between sleep physicians and dentists has become an essential part of modern care,” said Drewek. “Today’s best approach to managing chronic conditions is for teams to work together rather than treating each problem in isolation. This is especially important because many chronic conditions affect multiple body systems. When care happens in silos, important clues are missed, diagnoses are delayed, and patients often cycle through appointments without real improvement.”

Cultivating Collaboration

The growing burden of sleep disorders cannot be met effectively only by physicians who hold specialty training in sleep medicine, said Kevin Postol, DDS, president of the American Academy of Dental Sleep Medicine, an independent, self-designated nonprofit organization comprising dentists who treat snoring and OSA with OAT.

“The most effective model is a collaborative physician-dentist approach in which the physicians diagnose the sleep disorder and prescribe the appropriate therapy for severity and lifestyle, while qualified dentists conduct comprehensive oral evaluations to select the appropriate custom appliance, titrate it, and manage long-term follow-up and any dental or occlusal side effects,” said Postol.

“When both parties maintain structured communication with shared treatment progress and adherence data, the partnership will ensure that patients receive comprehensive care across the full continuum from diagnosis to long-term management.”

Although dental sleep medicine is not acknowledged as a formal specialty by the American Dental Association (ADA), it’s a field that has evolved significantly over more than 20 years and offers continuing education that the ADA recognizes. The practice also represents an advancement of dental medicine from a generally siloed area of care into one that is more collaborative today, said Postal.

“Dentists are traditionally very isolated individuals,” he said. “We refer patients out because we cannot diagnose [sleep disorder] patients. But we can help screen them and work with other physicians to make sure they get a proper diagnosis and then treat them from there. Many times, especially when it comes to OSA, there’s a multitude of ways to treating them.”

A Bidirectional Model and Best Practices

From the dental perspective, Postal said it’s obvious that more patients are being referred to respiratory physicians for consultation and vice versa with more referrals coming in from the respiratory side. He estimates that approximately 80% of his patients are referrals from sleep specialists with increasing caseloads also stemming from otolaryngologists and primary care.

“We’re seeing a clear trend toward integrated sleep care as the clinical use of oral appliances expands and awareness grows around the connection between sleep and overall health,” Postal said. “More practices are incorporating dental sleep medicine into their care pathways and combination therapy protocols further reinforce this interdisciplinary model.”

At Clayton Sleep Institute in St. Louis, CEO Joseph Ojile, MD, said that his referrals to dental sleep medicine generally lean toward the types of issues that involve sleep and breathing as opposed to sleep and breathing control. “Our dental sleep medicine colleagues have a lot to offer us,” said Ojile, a fellow of the American College of Chest Physicians and member of the American Thoracic Society. “And we have fully integrated the option of an oral appliance and dental medicine into our care plan when we talk to patients about their sleep study results.”

When determining where and when to refer, Ojile said he discusses the nature of each patient’s condition and their care goals with them. “If they have OSA, especially when it is mild or moderate, we offer all the solutions that are indicated for that amount of apnea,” he explained. “At a minimum, mild and moderate OSA deserves conversation about the airway control issues — airway pressure, OAT, and, frequently, weight optimization. If the patient decides they want to see someone for OAT consultation, they need an order from us and a copy of their sleep study. If they get an appliance, we perform follow-up testing to prove that the appliance is working properly. And we do that in conjunction with our dental sleep colleagues.”

When patients opt against OAT consultation or they are inclined to initiate CPAP first, Ojile leads them down that path. “We arrange for that, but we put it fully integrated into the decision tree,” he said. Patients likely to decline OAT usually include those who wear braces or retainers, those who have temporomandibular joint disorders, and those who have missing teeth. He estimates that at least 40% of his patients will also be living with underlying respiratory diagnoses including chronic obstructive pulmonary disease and asthma.

“And [OSA] is more common in that population for a variety of reasons,” Ojile said. “And we do have a large population of people who are sleep apnea patients alone.”

Among children, the most common somnipathy issue is sleep-disordered breathing, which is often caused by enlarged tonsils or adenoids and can change how the face and jaw grow when children chronically mouth breathe, said Drewek. “When the tongue rests low instead of against the roof of the mouth, the upper jaw may remain narrow, leaving less room for teeth and leading to crowding,” she explained.

“Bruxism is also common in children with sleep disruption. While it doesn’t cause narrow teeth, it can wear down enamel, crack teeth, and cause jaw pain. Treating the airway can improve both sleep and dental outcomes,” said Drewek.

Also among children, Drewek said patients are often referred to dental when airway-related jaw or facial features such as a narrow palate, crowded teeth, or jaw misalignment contribute to airway collapse and worsen OSA. “This bidirectional model, where sleep doctors and dentists routinely refer patients to each other and share responsibility for diagnosis, treatment, and follow-up, has been shown to improve early diagnosis, increase treatment adherence, and lead to better long-term outcomes,” she said.

Oral Appliance Observations

Custom OAT has emerged as a highly adherent alternative or adjunct to CPAP, said Postol. Once it’s determined that a patient is interested in an oral appliance, they’ll receive the necessary education with their referral, said Ojile. “I describe the appliance as an option to patients who have snoring or mild or moderate apnea, especially when their apnea hypopnea index is under 30. There are people who can be treated who have more severe apnea. But in our dialogue with patients, I want to make sure we include oral appliance as an option for mild or moderate apnea.”

Ojile said these patients can attempt OAT as a first-line treatment or if they decide that they can’t tolerate measures such as CPAP. “And of those patients, a higher percentage will go for OAT than it used to be. A percentage of those patients will proceed to have the appliance. And then we’ll conduct a follow-up home study. If they generally feel good, even with mild or moderate apnea, but want to stop snoring, the appliance can be a very good choice. If they have other comorbidities, they might still choose CPAP. But they will do that with receiving full information about all other options. I have an oral appliance in my office with a model and will demonstrate each to help patients understand how both therapies work.”

Ojile said he is seeing less stigma related to CPAP and more desire to know how their sleep and dental complications contribute to a higher risk for poor health outcomes. “Most patients today want to understand the dynamic, the anatomy, the therapy, and the pros and cons of their options,” he said. “For us, it is a full part of the integration and how we practice. Our patients seem to come back quite satisfied if they choose to proceed with OAT therapy. If they choose to not do the appliance, we always open the door.”

For those patients who receive a follow-up sleep study after OAT and the test does not indicate an adequate solution to their apnea, Ojile will consult with the sleep dentist who might consider the potential for more protrusion or, if matters have been exhausted, CPAP could be the suggested option. “And that’s completely fair,” said Ojile. “No therapy is perfect. But we need that collaboration to get to the positive outcomes. We’re not in a refer-and-forget mode.”

Drewek, Ojile, and Postol reported having no relevant financial relationships.