Dr. Daniel Taché discusses how sleep fragmentation from restless legs syndrome can lead to sleep-breathing issues.
by Daniel E. Taché, DMD
In 2015, the American Academy of Sleep Medicine endorsed the use Oral Airway Therapy (OAT) devices for the treatment of mild Obstructive Sleep Apnea (OSA) because evidence showed a sufficient level of efficacy.1 More recently, MAD therapy has shown “impressive amelioration of symptoms” with and satisfactory efficacy in the majority of patients provided with MADs who were diagnosed with moderate OSA.2
The prevalence of RLS in patients reporting disturbed sleep and pain from sleep bruxism is between 14% and 19%
Since 2015, commensurate with the favorable treatment outcomes with OAT therapy, there has been a significant increase in the number of dentists who are offering MAD therapy as an alternative to CPAP therapy, for the patients who present with appropriate structural phenotypes for an adequate response to repositioning of the mandible for control of OSA.
Adherence with OAT was, until recently, mostly limited to self-reported data. Based on this self-reported data, OAT adherence showed a wide range of adherence (4-76%).3 More recent objective evaluation showed adherence to OAT was 83% for the first year but declined to 62-64% after 4 or more years.4
The most common, self-reported reasons for discontinuing the OAT treatment are significant side-effects (e.g., jaw pain, headache and/or bite changes) and/or a substantial lack of perceived benefits (residual fatigue).5,6,7 Furthermore, many of these patients reported that they will awaken with significant symptoms suggestive of sleep bruxism (SB).
Historically, it was believed that SB was most often occurred shortly after respiratory-related events during sleep such as that in OSA or patients diagnosed with UARS. Furthermore, it was hypothesized that SB, characterized by rhythmic masticatory muscle activities (RMMAs) contributed to the restoration of a compromised upper airway during consequent to respiratory events. However, current evidence suggests that SB is more of a non-specific orofacial activity that is associated with numerous factors leading to sleep fragmentation but not solely respiratory events per se.8
Restless Legs Syndrome (RLS), is a highly prevalent sleep disorder which can cause significant sleep fragmentation leading to SB. RLS affects 5-10% of the general population who meet the standard diagnostic criteria for RLS.9 The prevalence of RLS in patients reporting disturbed sleep and pain from SB, is much higher ranging between 14% and 19%.
RLS suffers who reported discussing their symptoms with a healthcare provider more often received an erroneous diagnosis for their RLS symptoms such as: poor circulation (18.3%), arthritis (14.3%), back/spinal injury or problem (12.7%), varicose veins (7.5%) depression and anxiety (6.3%), and trapped nerve (5.6%). Typically, only 6.2% were given the correct diagnosis of RLS.10
The identification of the DSM patient with RLS is relatively simple but it all begins with the DSM clinician having a heightened awareness of the enormous prevalence of this significant affliction. The diagnosis of RLS is relatively simple because identifying RLS sufferers does not require a sleep study, it is a clinical diagnosis.
Clinical Pearl #1
Because RLS has such a high prevalence and can so degrade the quality of life of our patients, assume every DSM patient has RLS until he/she indicates that they are not so afflicted. Simply add the 4 questions below to your DSM intake/history forms.
Clinical Pearl #2
All DSM patients whose respiratory indices are normalized from OAT but despite an excellent response continue to have signs and symptoms of sleep-related bruxism and/or have persistent excessive daytime sleepiness, should be suspect of having RLS until your clinical interview of those patients, i.e., asking if he/she reports symptoms of RLS listed below:
Clinical Pearl #3
RLS is a very heritable condition and affects many members of the same family including children who may report “growing pains”.
Clinical Pearl #4
Most RLS patients have had this condition for their entire life and many will just dismiss it as a variant of their “normal” sleep. Be Persistent. Let them know that sleep bruxism & orofacial pain upon awakening and/or persistent fatigue are in fact, not “normal” and that treatment is typically quite simple and does not require a sleep study.
If you choose not to treat RLS but persist to help establish a diagnosis of RLS and refer such patients to a qualified clinician for treatment, you have done much for your patient. Because of such efforts, it may enable your patient(s) to remain compliant with OAT while also potentially experiencing enhanced health and markedly increased quality of life.
Whether your patients have restless legs syndrome or another sleep-breathing disorder, you need to uncover the why behind OSA treatment acceptance. Read more about it here: https://dentalsleeppractice.com/uncovering-behind-osa-treatment-acceptance/
- Li, D. K. (2022). Sleep bruxism is highly prevalent in adults with obstructive sleep apnea: a large-scale polysomnographic study. Journal of Clinical Sleep Medicine,jcsm-10348.
- Balasubramaniam, R. P. (2014). Sleep medicine education at dental schools in Australia and New Zealand. J Dent Sleep Med, 1(1), pp.9-16.
- Hoffstein, V. (2007). Review of oral appliances for treatment of sleep-disordered breathing. Sleep and Breathing, 11(1), pp.1-22.
- Walker-Engstrom ML, T. A. (2002). 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patientswith obstructive sleep apnea: a randomized study. Chest, 121(3), pp:739–746.
- Ramar, K. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015: an American Academy of Dental Sleep Medicine clinical practice guideline. Journal of clinical sleep medicine, 11(7), pp.7.
- Tallamraju, H. N. (2021). Factors influencing adherence to oral appliance therapy in adults with obstructive sleep apnea: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine, 17(7), pp.1485-1498.
- Izci, B. M. (2005). Clinical audit of subjects with snoring & sleep apnoea/hypopnoea syndrome fitted with mandibular repositioning splint. Respiratory medicine. 99(3), pp.337-346.
- Kuang, B. L. (2022). Associations between sleep bruxism and other sleep-related disorders in adults: A systematic review. Sleep Medicine. (89), pp.31-47.
- Lavigne, G. a. (1994). Restless legs syndrome and sleep bruxism: prevalence and association among Sleep, 17(8), pp.739-743.
- Allen RP, W. A. (2005). Restless Legs Syndrome Prevalence and Impact: REST General Population Study. Arch Intern Med., 165(11), pp:1286–1292.
- Attali, V. C. (2016). Predictors of long-term effectiveness to mandibular repositioning device treatment in obstructive sleep apnea patients after 1000 days. Sleep medicine (27), pp.107-114.
- Buyse B, N. P. ( 2023, 1). Short-term positive effects of a mandibular advancement device in a selected phenotype of patients with moderate obstructive sleep apnea: a prospective study. J Clin Sleep Med, 19(1), pp. 5–16.