Dr. Steven D. Bender shows how sleep and pain interactions need screening, referral, and management to provide treatment and a better lifestyle for patients.
by Steven D. Bender, DDS
The relationship between pain and sleep has been extensively studied but continues to remain ambiguous. It is widely accepted that poor sleep often precedes pain disorders, including temporomandibular disorders (TMDs)1 and that pain disorders can negatively impact sleep quality. It is therefore essential for dental teams involved in the clinical management of orofacial pains and dental sleep medicine to understand and recognize the frequent comorbidity of these two entities. Dental teams need also to understand the importance of working closely with physicians and when appropriate, comfortably refer patients to the appropriate provider in sleep medicine for further evaluation of any suspected sleep disorder. The aim of this article is to provide a brief overview of the current understanding of pain and sleep interactions in hopes that the dental team will be better prepared to confidently address these when encountered in practice.
Epidemiology of Sleep Disorders in Chronic Pain Patients
Sleep and pain both serve vital functions necessary for human survival. Dysregulation of either has the capacity to affect the other and ultimately interfere with optimum health. Approximately 10-25% of adults will experience some form of chronic pain defined as persistent or recurrent pain lasting ≥ 3 months.2,3,4 Recent data suggests that 50-90% of people with chronic pain also report poor sleep, specifically insomnia, prolonged sleep latency, poor sleep efficiency, and frequent awakenings after sleep onset.5-7
While various theories have been proposed as to the directionality of the relationship between sleep and pain, more recent longitudinal studies have shown that poor sleep tends to be more predictive of the onset of various pain disorders such as headaches,8,9 fibromyalgia,10 and musculoskeletal pains11 as opposed to pain conditions leading to poor sleep. The Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) study found that patients often experience a period of poor sleep months before the onset of new TMD related pains, independent from other variables.1
Nonrestorative sleep is defined as an unrefreshed feeling on awakening and is experienced in approximately 10% of the general population, particularly in older individuals. Patients with chronic pain conditions such as TMDs commonly report poor or unrefreshing sleep as indicated by frequent awakenings throughout the night, daytime drowsiness, issues with restless leg syndrome, and sleep-related breathing disorders (SRBDs). For some individuals, the restoration of a restful sleep (sleep that makes them feel refreshed and energized) has been associated with the resolution of chronic widespread pain.12
36% of patients with TMDs meet the criteria for insomnia.13,14 Insomnia may be suspected when sleep onset is longer than 20 to 30 minutes, and occurs three to five times a week, or if spontaneous awakening is present during the night without the ability to resume sleeping.15,16 It is estimated that approximately 10% of the general population suffers from chronic insomnia. However, the prevalence is reported to be approximately 30% in chronic pain patients.17
Factors such as lifestyle, beliefs, difficulties in coping with anxiety, poor physical fitness, and chronic fatigue can be considered risk factors for insomnia. Orofacial pain patients tend to report more problems in coping with fatigue, psychologic distress, headaches, abdominal pains, and sleep disturbances.14,18-20
Screening, Referral, and Management Considerations
As it is estimated that 5.9 million U.S. adults have obstructive sleep apnea (OSA) with up to 80% remaining undiagnosed, it is the responsibility of the dental team that participates in the care of orofacial pain patients to screen for any suspected sleep disorders that if present, could hinder treatment outcomes in the pain patient. Conversely, it is also critical for the dental sleep medicine practice to meticulously screen for the presence of TMDs or other orofacial pains that may interfere with the initiation of care of the patient with a sleep related breathing disorder. 21 Additionally, when indicated, the appropriate referral should be made for further evaluation, diagnosis, and any necessary therapies that may fall outside the scope of a dental practice. Management strategies for sleep disorders and orofacial pains will vary depending on the diagnosis and should be patient centered and individualized accordingly.
Management Considerations: Oral Appliances
Oral appliances may be utilized for both TMDs and SRBDs. While positive airway pressure (PAP) therapy is currently considered the gold standard treatment for SRBDs, oral devices designed to hold the mandible in a protruded position in relation to the maxilla during sleep, known as mandibular advancement devices (MADs), may also be offered as a first line of treatment for a large number of patients, especially with mild to moderate severity.22 MADs have been shown to provide comparable benefit in terms of quality of life, cognitive and functional outcomes as compared to PAP, and appear to have greater treatment compliance.23 Also, there is data to suggest that MADs may reduce the rhythmic masticatory muscle activity (RMMA) associated with some forms of sleep bruxism (SB).24-27 However, most of these studies are short term in duration (approximately 2 weeks). It should be noted that a recent scoping review found that in instrument-based studies utilizing electromyography and polysomnography, there was no significant correlation found between SB and TMDs.28 It should also be mentioned that while SRBDs may play a role in some SB manifestations, recent reviews have concluded that to date, there is insufficient evidence to support a conclusive cause and effect relationship between the two.29,30
Treatment strategies depend on the diagnosis and should be patient centered.
Other types of oral appliances have long been utilized to help manage various TMD complaints. While many hypotheses have been reported, there is currently no significant data to support any specific mechanism of action for these devices in their role as therapy for TMDs. Importantly, some reports have suggested that devices fabricated for the maxillary arch may increase the severity of OSA in some patients.31-33 The mechanism for this adverse response is currently not known.
Management Considerations: Pharmacotherapy
The goals of pharmacotherapy in orofacial pain and sleep disturbances will vary depending on the specific diagnosis and individual patient characteristics but will have the common objective of reducing pain and improving sleep. Mild analgesics are commonly used alone or in combination with muscle relaxants or other sedating agents to help manage some orofacial pain conditions. Benzodiazepines, which act on gamma amino butyric acid (GABA)-A receptors in the CNS, tend to shorten sleep latency and increase sleep duration in most individuals. They are anxiolytic and sedating and have demonstrated positive outcomes in chronic TMD pain34,35 and in patients with SB.36 However, benzodiazepines will tend to decrease REM stage sleep.37 Cyclobenzaprine, used commonly in the management of musculoskeletal pains, is frequently used in the management of muscle related TMDs. It has been shown to be beneficial in reducing morning TMD related pain as well as improving subjective sleep quality.38 Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), is approved by the US Food and Drug Administration (FDA) for the treatment of widespread pain/fibromyalgia. While there appears to be an increase in deeper stages of sleep with duloxetine, REM stage sleep is often suppressed.39 Other medications, such as tricyclic antidepressants (e.g., amitriptyline) have mild to moderate positive effects on both pain and sleep. The positive effects of amitriptyline have been documented for the management of some orofacial neuropathic pains40 as well as chronic tension-type headache.41 Gabapentin and pregabalin, which appear to work at the voltage sensitive calcium channels, also appear to improve pain and sleep quality and continuity.42 The use of opioids in the management of chronic pain is still common despite the potential for tolerance and substance use disorders, as well as the development of opioid induced hyperalgesia. In addition, the risk of respiratory depression associated with opioid use is of significant concern, particularly in patients with SRBDs.
While it has been traditionally believed that some psychotropic medications may induce or worsen both awake bruxism and SB, a recent review found that there is insufficient evidence to draw any such conclusions.43
Sleep is a vital physiologic activity that normally occupies approximately ⅓ of an individual’s life. There appears to be a bidirectional relationship between pain and sleep. Sleep disturbances and sleep disorders can lead to pain disorders and can negatively impact pain management therapy, and acute and chronic pain conditions can disturb sleep. Dental teams should be acutely aware that many patients presenting with orofacial pains frequently suffer with sleep disorders. When sleep disorders are suspected in the orofacial pain patient, the team should understand their role in screening and how to make the most appropriate referrals for accurate diagnosis and comprehensive care. In addition, the dental sleep medicine team should be acutely aware of the impact of any existing orofacial pains, including TMDs may have on their ability to successfully manage SRBDs.
Ben-Pat Institute has a continuing education course that informs clinicians about sleep and pain interactions. Read more about it here: https://dentalsleeppractice.com/there-is-an-interrelationship-between-pain-and-sleep/
- Sanders AE, Akinkugbe AA, Bair E, et al. Subjective Sleep Quality Deteriorates Before Development of Painful Temporomandibular Disorder. J Pain 2016;17(6):669-77.
- Scholz J, Finnerup NB, Attal N, et al. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain 2019;160(1):53-59.
- Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health 2011;11:770.
- Henderson JV, Harrison CM, Britt HC, Bayram CF, Miller GC. Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients. Pain Med 2013;14(9):1346-61.
- Cheatle MD, Foster S, Pinkett A, et al. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Anesthesiol Clin 2016;34(2):379-93.
- de Tommaso M, Delussi M, Vecchio E, et al. Sleep features and central sensitization symptoms in primary headache patients. J Headache Pain 2014;15:64.
- Odegard SS, Sand T, Engstrom M, Zwart JA, Hagen K. The impact of headache and chronic musculoskeletal complaints on the risk of insomnia: longitudinal data from the Nord-Trondelag health study. J Headache Pain 2013;14:24.
- Boardman HF, Thomas E, Millson DS, Croft PR. The natural history of headache: predictors of onset and recovery. Cephalalgia 2006;26(9):1080-8.
- Odegard SS, Sand T, Engstrom M, et al. The long-term effect of insomnia on primary headaches: a prospective population-based cohort study (HUNT-2 and HUNT-3). Headache 2011;51(4):570-80.
- Mork PJ, Nilsen TI. Sleep problems and risk of fibromyalgia: longitudinal data on an adult female population in Norway. Arthritis Rheum 2012;64(1):281-4.
- Nitter AK, Pripp AH, Forseth KO. Are sleep problems and non-specific health complaints risk factors for chronic pain? A prospective population-based study with 17 year follow-up. Scand J Pain 2012;3(4):210-17.
- Lavigne GJ, Nashed A, Manzini C, Carra MC. Does sleep differ among patients with common musculoskeletal pain disorders? Curr Rheumatol Rep 2011;13(6):535-42.
- Davies KA, Macfarlane GJ, Nicholl BI, et al. Restorative sleep predicts the resolution of chronic widespread pain: results from the EPIFUND study. Rheumatology (Oxford) 2008;47(12):
- Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep 2009;32(6):779-90.
- The International Classification of Sleep Disorders: (ICSD-3): American Academy of Sleep Medicine; 2014.
- Lavigne GJ HR, Cistulli PA, Smith MT. Classification of sleep disorders. In: Lavigne GJ CP, Smith MT editor. Sleep Medicine for Dentists: A Practical Overview. Chicago: Quintessence; 2009. p. 21-31.
- Lavigne GJ SM, Denis R, Zucconi M. Pain and Sleep. In: Kryger HM RT, Dement WC, editor. Principles and Practice of Sleep Medicine. Philadelphia: Elsevire Saunders; 2011. p. 1442-51.
- de Leeuw R, Studts JL, Carlson CR. Fatigue and fatigue-related symptoms in an orofacial pain population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99(2):168-74.
- Goncalves DA, Camparis CM, Speciali JG, et al. Temporomandibular disorders are differentially associated with headache diagnoses: a controlled study. Clin J Pain 2011;27(7):611-5.
- Macfarlane TV, Blinkhorn AS, Davies RM, et al. Orofacial pain: just another chronic pain? Results from a population-based survey. Pain 2002;99(3):453-58.
- Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013;177(9):1006-14.
- Ramar K, Dort LC, Katz SG, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773-827.
- Schwartz M, Acosta L, Hung YL, Padilla M, Enciso R. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath 2018;22(3):555-68.
- Landry-Schonbeck A, de Grandmont P, Rompre PH, Lavigne GJ. Effect of an adjustable mandibular advancement appliance on sleep bruxism: a crossover sleep laboratory study. Int J Prosthodont 2009;22(3):251-9.
- Landry ML, Rompre PH, Manzini C, et al. Reduction of sleep bruxism using a mandibular advancement device: an experimental controlled study. Int J Prosthodont 2006;19(6):549-56.
- Franco L, Rompre PH, de Grandmont P, Abe S, Lavigne GJ. A mandibular advancement appliance reduces pain and rhythmic masticatory muscle activity in patients with morning headache. J Orofac Pain 2011;25(3):240-9.
- Saueressig AC, Mainieri VC, Grossi PK, et al. Analysis of the influence of a mandibular advancement device on sleep and sleep bruxism scores by means of the BiteStrip and the Sleep Assessment Questionnaire. Int J Prosthodont 2010;23(3):204-13.
- Manfredini D, Lobbezoo F. Sleep bruxism and temporomandibular disorders: A scoping review of the literature. J Dent 2021;111:103711.
- da Costa Lopes AJ, Cunha TCA, Monteiro MCM, et al. Is there an association between sleep bruxism and obstructive sleep apnea syndrome? A systematic review. Sleep Breath 2020;24(3):913-21.
- Pauletto P, Polmann H, Conti Reus J, et al. Sleep bruxism and obstructive sleep apnea: association, causality or spurious finding? A scoping review. Sleep 2022;45(7).
- Nikolopoulou M, Ahlberg J, Visscher CM, et al. Effects of occlusal stabilization splints on obstructive sleep apnea: a randomized controlled trial. J Orofac Pain 2013;27(3):199-205.
- Gagnon Y, Mayer P, Morisson F, Rompre PH, Lavigne GJ. Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study. Int J Prosthodont 2004;17(4):447-53.
- Hans MG, Nelson S, Luks VG, Lorkovich P, Baek SJ. Comparison of two dental devices for treatment of obstructive sleep apnea syndrome (OSAS). Am J Orthod Dentofacial Orthop 1997;111(5):562-70.
- Harkins S, Linford J, Cohen J, Kramer T, Cueva L. Administration of clonazepam in the treatment of TMD and associated myofascial pain: a double-blind pilot study. J Craniomandib Disord 1991;5(3):179-86.
- Singer E, Dionne R. A controlled evaluation of ibuprofen and diazepam for chronic orofacial muscle pain. J Orofac Pain 1997;11(2):139-46.
- Saletu A, Parapatics S, Saletu B, et al. On the pharmacotherapy of sleep bruxism: placebo-controlled polysomnographic and psychometric studies with clonazepam. Neuropsychobiology 2005;51(4):214-25.
- de Mendonca FMR, de Mendonca G, Souza LC, et al. Benzodiazepines and Sleep Architecture: A Systematic Review. CNS Neurol Disord Drug Targets 2023;22(2):172-79.
- Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J Orofac Pain 2002;16(1):64-70.
- Kluge M, Schussler P, Steiger A. Duloxetine increases stage 3 sleep and suppresses rapid eye movement (REM) sleep in patients with major depression. Eur Neuropsychopharmacol 2007;17(8):527-31.
- Sharav Y, Singer E, Schmidt E, Dionne RA, Dubner R. The analgesic effect of amitriptyline on chronic facial pain. Pain 1987;31(2):199-209.
- Ashina S, Bendtsen L, Jensen R. Analgesic effect of amitriptyline in chronic tension-type headache is not directly related to serotonin reuptake inhibition. Pain 2004;108(1-2):108-14.
- Hindmarch I, Dawson J, Stanley N. A double-blind study in healthy volunteers to assess the effects on sleep of pregabalin compared with alprazolam and placebo. Sleep 2005;28(2):
- de Baat C, Verhoeff M, Ahlberg J, et al. Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism. J Oral Rehabil 2021;48(3):