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Inside Dentistry
October 2012
Volume 8, Issue 10

What’s Hiding Behind the Smile?

Sleep disorders, Eating disorders, Substance abuse, Domestic violence–some cases have more going on than meets the eye.

By Allison M. DiMatteo, BA, MPS; and Terri Rafferty, BA, MA

Dentists are often their patients’ first line of defense and intervention for problems extending beyond the smile. These could involve sleep breathing, eating, and substance-abuse disorders, as well as domestic violence. In some cases, the signs and symptoms are apparent, as in the case of lingual tooth wear and erosion signifying acid reflux or repetitive regurgitation from anorexia or bulimia. The signs could be the soft and almost malleable tooth surfaces and structure often seen concurrent with methamphetamine use (ie, “meth mouth”). In other cases, chipped, fractured, or avulsed teeth resulting from a violent incident may be explained away, leaving the true cause suspect.

This month’s feature explores the roles of dentists and their staff in addressing conditions that affect more than the oral cavity. From helping to manage sleep breathing disorders to identifying and treating the oral symptoms of eating disorders, and from treating patients battling drug addiction to helping restore the lives of those shattered by domestic violence, today’s oral healthcare profession affords dentists and their team members an opportunity to assume a more significant place in establishing their patients’ overall well-being.

Sleep Disorders

Dentists’ role in treating sleep apnea has grown since the 1960s when it was recognized as a disease.1 Millions of people worldwide live with and endure sleep-disordered breathing, resulting in poorer life quality. Statistics suggest that among the adult population, 4% to 6% of men and approximately 2% of women suffer from sleep apnea or other sleep breathing disorder.2 Although rare, the worst cases of sleep apnea are life-threatening.3

As sleep disorders be more prevalent among the population, dentists have be an instrumental force in their management, with dentists and physicians establishing a collaborative working relationship.4 Medical sleep specialists and dentists combine efforts and skill sets to form a “sleep team,” a concept ultimately benefitting patients who receive more proficient and focused care.3

Dentists are not the primary care providers for patients with upper airway sleep disorders, however. But, because these disorders can be successfully treated with oral appliance therapy, dentists can now be responsible for treating patients referred to them by physicians.5 Following the established and required procedures when fabricating, inserting, titrating, and providing follow-up care for oral appliance therapy is essential to this process.5

According to Larry Twersky, CEO of, there are differences state by state governing the boundaries of how dentists can intervene and identify sleep apnea. In most states dentists can either administer a sleep apnea test or screen for the condition, but they cannot diagnose it or prescribe a specific treatment. Tests must be interpreted by physicians. In other states such as New Jersey, dentists are prohibited from administering the tests; only a physician can do that.

Although dentists cannot treat medical problems such as sleep disordered breathing with an oral appliance without a correct diagnosis of the disorder, which can only be rendered by a physician and requires a sleep study, they do need the knowledge to assess the risks and benefits of specific dental treatment options for patients with these problems.2,5 If dentists only treat snoring and do not check for sleep apnea, they are mismanaging patients in the eyes of the American Association of Dental Sleep Medicine, because sleep apnea needs to be ruled out as a standard of care before they provide a snoring appliance, Twersky emphasizes.

Identifying patients at risk for, and counseling them about, sleep disorders are part of maintaining awareness in the patient population of including oral appliance therapy in managing snoring and certain sleep-related breathing disorders.5 Risk factors include increased age, male gender, and maxillofacial abnormalities.6 Patients at high risk for obstructive sleep apnea (OSA) include those who are obese, have a history of congestive heart failure, atrial fibrillation, treatment refractory hypertension, stroke, type 2 diabetes, nocturnal dysrhythmias, pulmonary hypertension, individuals undergoing weight loss surgery, or are part of the high-risk driving populations (eg, truck drivers).7

Patients should be educated with as much information as possible, including symptoms of the disorder(s), possible side effects, and courses of treatment. Patients suspected of having and/or diagnosed with obstructive sleep apnea have years of onset symptoms they’re probably unaware of. These symptoms include extreme daytime sleepiness, chronic fatigue, and consistent snoring. Connections between sleep-related breathing disorders and vascular complications such as hypertension, coronary heart disease, and stroke also should be explained.6

Treating and managing OSA begins with a sleep-oriented history and physical examination during which querying about history of snoring, daytime sleepiness, and an evaluation for the presence of obesity, retrognathia, and hypertension are conducted.7 If the possibility of OSA exists, then the severity of the disorder must be diagnosed before treatment begins to determine the likelihood for developing complications. The appropriate baseline and treatment is then established to garner the most successful results for the patient.

Oral appliances are widely used to treat sleep disordered breathing, can lessen the severity of sleep respiratory issues by 60%, and have an acceptance rate of 70%.6 However, long-term complications of oral appliances include occlusal changes and temporomandibular joint di comfort.6

There are an estimated 40 types of oral appliances categorized by either mode of action or design, two of which are tongue-retaining devices and the mandibular advancement devices (MAD).8 Mandibular repositioning devices have been used successfully to treat snoring and mild to moderate sleep apnea.9 Both types have benefits and disadvantages, the latter involving cost and production issues.8

For severe sleep disorders such as OSA, the most recommended treatment with a 70% acceptance rate is nasal continuous positive airway pressure (CPAP).6 This treatment requires patients to wear a mask that exerts pressure on the upper airway while they sleep at night.

Maxillofacial surgery is the last resort and is only reserved for patients who haven’t responded to other available treatments for OSA.6 In particular, maxillomandibular advancement (MMA) has been successful but is still debated in the medical community. The single-stage surgery can help reduce OSA-related health risks, but it requires a collaborative working relationship between dentist and sleep physician.10

Because dentists’ role in sleep disorders has expanded so greatly over the past 10 years, it is imperative they receive appropriate education and training to correctly and safely approach sleep disorder cases as they are presented. However, exercising scrutiny when selecting from among various education sources is recommended to ensure educational materials and presentations are consistent with legal or professional ethics to avoid dilemmas.11

Organizations exist to assist dentists, surgeons, sleep medicine specialists, and primary caregivers in treating and proving long-term care to adult patients with OSA.7 Additionally, training for correctly using oral appliances for sleep breathing disorders is available to dentists that conforms to medical guidelines for distinguishing between patients who are simple snorers and those who should be referred for specialist assessment.9 Twersky advises becoming a member of the American Academy of Dental Sleep Medicine, which provides courses and guidelines for ruling out a variety of conditions related to sleep breathing disorders—not just apnea. He also cautions dentists not to pigeonhole themselves into only focusing on one particular appliance product.

Eating Disorders

Regrettably, the reported frequency of bulimia nervosa has risen significantly over the past 40 years. As such, dentists will likely encounter patients battling eating disorders.12 While eating disorders are prevalent among both genders, females tend to have eating disorders more than men.13 Statistics indicate that an estimated 0.5% to 1% of adult women and adolescent girls have anorexia nervosa and 1% to 2% show symptoms of bulimia nervosa. Ten percent of women and young girls show signs of excessive behavior, such as strenuous exercise, consistent dieting, and vomiting, that could eventually lead to an eating disorder.14

Their teeth often display several tell-tale signs of their disorder, such as wear, erosion, and caries.15 Signs also include xerostomia, enlarged parotid glands, traumatized oral mucosa, and other oral manifestations.16 Often, the patient’s dental and mental health continues to deteriorate as their disorder progresses if they do not receive proper treatment.15 Therefore, dentists should be aware of all signs of eating disorders so they can inform and offer advice to patients regarding the disorder and seeking treatment.17

Because eating disorders are disturbances in eating behavior with widespread effects, knowledge of behavioral management of eating disorders is beneficial. Dentists with this knowledge are better equipped to provide successful dental management, combined with a holistic approach to patient care.18 When it comes to treating anorexia nervosa and bulimia nervosa, highlighting the oral implications is essential. In order to proceed with treatment, many believe patients must receive psychotherapy and stop vomiting first.19

“Our philosophy for the last 40 years has been the opposite. We have intervened for these patients, and when you think about the reality of what happens dentally with an eating disorder patient, they’ve lost all their enamel, the teeth can be very sensitive, abscessed, or fragile, or fracture,” explains Thomas J. Balshi, DDS, PhD, of Pi Dental Implant Center. “They are in pain, and some dentists tell them that in order for them to be treated, they have to be cured of their eating disorder. But how can these patients think of putting food in their mouths to eat when they’re in pain.”

Balshi explains that dental professionals must deal with getting eating disorder patients out of pain and help them regain their self-esteem, which is critically important to the healing process for eating disorder patients. He believes the dental profession’s philosophy needs to take a second look at how it approaches these patients.

Unfortunately, there are no official guidelines for dentists to follow for providing support to patients regarding their eating disorder.20 Most dental practices don’t have an action plan for handling patients suspected of having eating disorders, and some fear offending or approaching patients on the subject, or of misdiagnosis.14 While female dentists tend to have more knowledge regarding eating disorders than their male counterparts, they have greater difficulty talking to patients and/or the parents of patients suspected of having an eating disorder than their male peers.21

“We treat them as any other normal human being, recognizing that they have another problem, but that is something we have to deal with. It’s akin to patients walking through the door who need very sophisticated and advanced dentistry and happen to be post-cancer treatment patients or have had a major cardiac issue,” Balshi says. “There are medical issues that patients come to us with that we must consider, but we need to manage them from a dental perspective.”

Like any other patient, the first thing dentists would do with an eating disorder or any other patient is make a diagnosis. It’s often during the initial or diagnostic visit that dentists discover that the patient has an eating disorder, Balshi elaborates. Sometimes it’s readily apparent clinically, sometimes it’s very subtly apparent, and sometimes patients will readily admit to it.

Most dentists aren’t familiar with available referral resources, or what the next step would be in behavior management treatment. Media sources, specifically newspapers and television, are the primary information sources for dentists regarding eating disorders, not educational training.21 Additionally, the role of dentists in intervening in eating disorder cases is often diminished and undervalued in the medical community due to a lack of working relationships between the dental and physician communities.14,16

“The severity of this disease is not insignificant. We as professionals really must understand that eating disorders are extremely serious to the point where they can be fatal. We are dealing with a medical issue that has a mortality attached to it that is no different than severe atherosclerosis and coronary artery disease,” Balshi emphasizes. “We can’t ignore these patients, especially if they have not admitted to it and are not under any formal treatment program.”

Chronic Headaches

It’s not u common for dentists to encounter patients in the practice with chronic pain, whether jaw or myofacial related.35 Pain symptoms could involve the face, jaw, ears, head, and neck muscle, in addition to chronic headaches, migraines, and a host of other symptoms.36-38

More than 29 million Americans suffer from migraines due to trigger factors that excite brain cells and cause a reaction in the trigeminal nerve that results in pain.39 Migraine sufferers lose more than 157 million work and school days each year due to pain.40 Additionally, an estimated 90% of the population suffers from headaches.40

Nearly 20% of Americans with chronic headaches seek professional help when over-the-counter medications have failed.39 They also embrace non-pharmacological techniques, in addition to those involving physical medicine.40

Chronic headaches, migraines, and TMJ disorders have been treated by various dental and medical specialists. According to the American Dental Association (ADA), dentists are appropriately trained and knowledgeable to diagnose and treat these conditions.41

“As dentists, our expertise involves not only treating the teeth, gingival tissues, and oral cavity, but also caring for the muscles of the head, neck and jaw, as well as the nervous system of these areas,” explains Charles W. Martin, DDS, a private practitioner in Richmond, Virginia, who diagnoses and treats patients with dentomandibular sensorimotor dysfunction. “The trigeminal nerve transmits pain impulses, as well as the majority of sensations originating from the head and neck region. Dentists know the sites where these impulses can be modified and arrested.”

Dentists can clinically manage these conditions by controlling pain and inflammation and rehabilitating the dentomandibular system to normal function and range of motion. Using neuroscience, systematic and objective diagnosis/monitoring, and proven sports medicine technologies and methods that are now available for dentistry, dentists can provide a long-term solution and healing framework for patients suffering with force-related disorders of the head and neck, TMJ, and the common neurology of these structures (ie, dentomandibular sensorimotor dysfunction).36,38,42-47

“Treatment protocols involving low-level laser therapy, therapeutic ultrasound, and microcurrent nerve stimulation can be directed to pain/headache/migraine rehabilitation, or to degenerative sensorimotor dysfunction that destroys teeth and restorations,” Martin explains. “In either case, appropriately treating the patient requires a full understanding of their condition and its causes to best relieve and prevent their pain long term.”

A comprehensive examination and head health, medical, and headache history, as well as a pharmacological assessment, help determine if an individual’s condition would be amenable and responsive to advanced therapeutic treatment. Objective digital diagnostics also help document the factors contributing to, and the extent of, the patient’s condition.

“At least 50% of a dentist’s existing patients could most likely benefit from this type of diagnostic and rehabilitation service, since it can measurably improve their quality of life,” Martin says. “Pain relief is not elective, and freeing our patients from pain is something our profession has always prided itself on. Addressing their chronic headache issues is no different.”

Drug Abuse

When drug users be addicts, their need for the drug and getting high supersedes anything else, including dental care. A majority of addicts have poor oral hygiene and extensive dental damage, although the levels of dental disease vary depending on the extent of abuse and type of drug used.22 Studies have shown that the dental effects of drug abuse vary among races. After years of narcotics use, African-American addicts have the least amount of remaining teeth, and African Americans and Hispanics are less likely to use dental services than Caucasian users.23

Rotten teeth, abscesses, dental decay, toothaches, tooth loss, and low saliva secretion are among the oral signs and symptoms of drug abuse, although these conditions certainly have other causes.24 Among the drugs patients may abuse that cause dental problems are cocaine, methamphetamine, ecstasy, and opiates.

Patients abusing cocaine typically present with gingival lesions, tooth surface erosion, and perforation of the nasal septum and palate. Ulceration and atropy of the tissues, direct smearing of the oral mucosa, especially the gingiva, and stimulant effects on the facial and masticatory muscles, may also be present.24

It’s imperative to understand that there are increased risks when performing dental procedures if a patient is under the influence of cocaine, such as a greater increase of a medical emergency specifically when epinephrine-containing local anesthetics or retraction cords are used.25 It is recommended that dentists postpone dental treatments for 6 to 24 hours until patients are no longer under the influence.26

Ecstasy, XTC, or methylenedioxymethamphetamine is used by young adults in large metropolitan cities and urban areas.27 Among the many symptoms of ecstasy abuse are xerostomia, bruxism, and a greater likelihood of developing dental erosion. Ecstasy users also can experience depression, panic disorders, psychotic episodes, impulsive behavior, and life-threatening conditions such as liver failure, hyperthermia, and hyponatraemia. Another sign of abuse is changes in the oral mucosa.28

Worldwide, 35 million people are methamphetamine (meth) users. In the United States, 10.4 million people are users, although this number is declining.29 Oral symptoms of meth abuse include dental disease, missing teeth, broken or lose teeth, bruxism, and dentin erosion.30 Other symptoms include black, stained, and rotting teeth. In a majority of cases, teeth are so damaged that they require extraction.31 “Meth mouth,” a specific pattern of oral signs and symptoms indicating meth use, is characterized by excessive caries, tooth fracture, and weakening of tooth structure.32

In terms of opioid abuse, 12% of users have been prescribed the medication to treat a medical ailment, while 23% have taken the drug for non-medical reasons. Dentists could have a significant role in intervening in opioid abuse through patient assessment and education, referring patients to substance abuse treatment, and utilizing prescription-monitoring programs.33

According to Matthew Messina, DDS, consumer advisor for the American Dental Association, it is difficult to determine the percentage of the dental patient population that could benefit from dentists intervening when they suspect drug abuse. There is a wide variation in the estimates of the percentage of the population believed to have a substance abuse disorder. For someone with a substance use problem, proper intervention and support by their healthcare team would clearly help 100% of these patients, he says.

Although until recently there has been a lack of programs and resources for dental professionals about how to address and treat patients battling drug abuse, there is a call to action within the healthcare community to create programs similar to tobacco-use cessation efforts. These would give dentists the resources and tools to help patients regain oral function and reshape their overall image, instilling self-confidence by re-establishing oral health. This step could help patients recover from drug abuse and deconstruct their “drug user” persona.30 Additionally, establishing open lines of communication between the dental and medical communities can greatly facilitate appropriate steps toward ensuring patients battling drug use receive the treatments and care they need.34

“Dentists are encouraged to be knowledgeable about substance use disorders and take this into consideration when planning treatment and prescribing medications,” Messina explains. “Dentists also are encouraged to be familiar with their community’s treatment resources for patients with substance use disorders.”

Unfortunately, addicts typically fear dentists and facing the scorn and judgment of being “outed” as a drug user.34 When patients suspected of or known to have drug abuse problems do present, it is imperative that dentists and team members recognize their special dental conditions—such as sensitive teeth and low pain tolerance—and try to establish a trusting rapport that acknowledges their need for care.24

“If substance abuse is suspected or a history of substance abuse exists, the dentist is encouraged to seek consultation with the patient’s physician so that a team approach to treatment can occur,” Messina emphasizes. “We have to discuss our concerns about drug abuse with the patient, but if they refuse to allow us to discuss our concerns with others, the dentist may be constrained by state and federal law. It’s a tricky situation.”

Domestic Violence

An estimated 1.5 million women in the United States sustain serious injury from sexual or physical assault, and it’s been reported that more than 50% of female homicides result from domestic violence.48

In every state, physicians and dentists have a legal obligation to report suspected cases of child abuse and neglect to social services or law enforcement agencies.49 However, only some states require suspected cases of domestic violence to be reported. For most dentists it’s a personal choice to report domestic violence to authorities.50

Most domestic violence victims show indications of abuse and want their dental team to recognize the signs and provide assistance and referrals for help and treatment. The most universal target of domestic abuse is the face, and strangulation is a serious indicator of severe domestic violence that is usually disregarded.51,52

However, according to Kenneth L. Banks, DDS, a dentist who participates in the American Academy of Cosmetic Dentistry’s (AACD) Give Back a Smile Program, dental issues from domestic violence do not only involve trauma. Decay, decalcification, and damage also occur from neglect as a result of emotional abuse and the victim being unable or allowed to seek appropriate dental care.

Several other signs indicate child abuse or neglect, including bite marks, perioral and intraoral injuries, infections, and diseases, as well as caries, gingivitis, contusions, burns, lacerations of the tongue, lips, buccal mucosa, soft and hard palate, alveolar mucosa, fractured or displaced teeth, or jaw and bone fractures.49 Other signs are discolored teeth, bruises, scarring at the corner of the mouth, posterior pharyngeal injuries, and retropharyngeal abscesses.49

Dentists can create a safe and secure place for victims. Concurrently, dental offices also can be equipped to inform patients about local resources, recommend strategies to promote safety, provide supportive messages, and educate patients about the effects of abuse to overall and dental health.53

To begin, the AVDR (ie, asking, validating, documenting, and referring) tool can facilitate communication with patients on an appropriate level to ensure they receive the best possible care. Dentists or their team members ask the patient about the injury or accident, provide validating messages about the wrongs of battering and reinforce that the victim is not at fault, document the signs and symptoms as well as anything the patient has said or done while communicating about the incident, and finally refer victims to a domestic violence specialist. It is important for dentists to remember that it is not their responsibility to solve the problem for their patient, nor should patients assume that their dentist can solve their problems.50

“There’s a fine line. The patient would have to open up at some point and tell the dentist there’s been trauma,” explains Banks. “We can ask questions, but they have to open up at some point. If it wasn’t a Give Back a Smile patient, then there are agencies that dentists could refer them to and help them obtain the assistance they need.”

While dentists can treat the oral complications stemming from child abuse and neglect, the biggest form of treatment they can provide is reporting all signs of abuse for investigation. Because abuse is not contingent upon one body area, dentists and physicians should have a good “working relationship” so they may confer about how to treat a patient and provide the best possible overall care.49

Several organizations provide guidelines, support, and information for dental professionals about addressing potential cases of abuse, neglect, and domestic violence. The American Academy of Pediatrics has established guidelines and information for the medical community regarding child abuse and/or neglect examinations called “Guidelines in the Evaluation of Sexual Abuse of Children.”49 Prevent Dental Abuse and Neglect Through Dental Awareness (PANDA) is a coalition working to train and educate nurses, physicians, dentists, dental auxiliaries, teachers, and childcare providers to recognize signs of suspected abuse, talk to individuals, and take the next steps in getting help for the victim.49 The American Board of Forensic Odontology (ABFO) has created a photographic scale to document a patient’s patterned injuries.49

Once intervention has already taken place, the patient is removed from the violent relationship, and has broken ties with the abusive partner, programs like Give Back a Smile help them restore their smiles—and their lives—at no cost to them, explains Banks, who has treated three domestic violence survivors in his area. Banks says he and many AACD members rely on agencies like the AACD and the Give Back a Smile Program to get involved and serve as a main resource for domestic violence cases.

“Every case is different because every individual is different,” Banks admits. “The biggest common issue I see is that the patient’s self-esteem is low and they don’t feel worthy of anything. As you treat them, their personality changes, their self-esteem starts coming back, and they feel more worthwhile and grateful, and you see the person change right before your eyes.”


Regardless of the specific cause of the problem that drove the patient to seek care from their dentist, when faced with individuals who present with problems that extend beyond the smile, dentists are challenged to understand the boundaries governing their intervention and the limits of what their skills and talents can accomplish.

“If you’re going to offer sleep-disordered breathing services, do it right or refer out your first few cases and watch an expert walk through the process,” Twersky advises. “Work with a mentor, establish a support system, and follow along with a study club dedicated just to sleep breathing disorders.”

Balshi asserts that dentists are obligated as medical professionals to encourage patients who won’t admit to their eating disorders—a disease with a mortality attached to it—to seek additional treatment. He says the bottom line is that once dentists have established the knowledge factor that an individual has an eating disorder, they need to be involved in recommending adjunctive care.

“Substance abuse is a difficult issue in society as a whole, and the challenges that we have as dentists mirror these problems,” Messina says. “We care deeply about our patients’ health and well-being, but there are limits to what we can do to help people help themselves. If a patient is seeking help, we can be invaluable as a resource and support system for them. If they do not want help, there is little we can do to force it on them.”

Fortunately, there are resources and specific support mechanisms that can guide dentists and their staff in treating and referring patients to other agencies and professionals so that an individual’s overall well being is properly managed. In other cases, dentists can be the ideal first line of defense, treatment, and intervention.


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