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Inside Dental Hygiene
June 2023

Don’t Ignore the Snore!

Expanding the Risk Assessment Protocol for Sleep Disorders Can Make a World of Difference for Patients

Kelley Quolas, BSDH, QOM, RDH

If I were to ask an audience of dental professionals if they understand the systemic connection between the oral cavity and whole-body health, the answer would be an automatic "Heck yes!" However, there is still a need to update our risk assessment protocols in the office to take this into account for our patients. We have learned about the impacts of nutrition, smoking, and alcohol use on oral health, but what about the huge impact of restorative sleep and oral breathing?

In 2017, the ADA recommended that all patients be screened for sleep disorders.1 One study estimated that the overall prevalence of mild to severe sleep disordered breathing (AHI ≥5) among those 30-70 years of age is 26%.2

Dentists and dental hygienists are working in the "airway" space daily. We are also on the front lines to assess risk factors for disease prevention and management. We are obtaining blood pressure readings, reviewing medications and health histories, performing intra and extra oral exams, and obtaining markers for oral health. These markers also allow us to have some insight into what is going on systemically.

Oral manifestations, anatomical markers, and pathology can offer a segue into a discussion with your patient about their sleep and breathing quality. This could save their life!

Health risks associated with sleep disordered breathing and oral breathing include:

• poor mental health.

• increased risk of stroke.

• increased risk of cardiovascular disease, including hypertension.

• increased risk of dementia.

• increased risk of a motor vehicle accident.

• increased risk of caries.

• increased risk of periodontal disease.

• increased risk of tooth fractures.

• lower blood oxygen levels.

• increased frequency of illness.

• acid reflux/digestive issues.

In addition, sleep disordered breathing does not occur only within the adult population. It is reported that "significant sleep disturbance occurs in about 25% of children and adolescents," as well.3

The standard treatment for children who exhibit symptoms of sleep disorders is usually tonsil and adenoid removal. Recent research suggests that palatal expansion may also serve as an intervention strategy to increase the volume of the upper airway, therefore allowing increased airflow and oxygenation for the sleep disturbed child.4 Furthermore, orofacial myofunctional therapy can be a great, non-invasive treatment option for both adults and children. It helps to support the tongue and upper airway muscles and emphasizes nasal breathing with neuromuscular exercises. Orofacial myofunctional therapy has been shown to be 50% effective in adults and 62% effective in children in decreasing apenic and hypopnic events during sleep.5

There are simple visual markers you can notate, which you most likely are documenting anyway during the appointment. Markers that are indicative of the patient being at higher risk for sleep disordered breathing and oral breathing include:

• lasia, especially around the maxillary anterior centrals/incisors.

• scalloped tongue.

• white, coated lingual papillae.

• wear faucets on molars.

• attrition on the incisal edges.

• limited elevation from the soft palate and elongated uvula.

• narrowing of the palate and/or missing teeth.

• open bites (anterior and/or posterior), including orthodontic relapse.

• enlarged tonsils.

If you need a visual representation, provides a simple screening tool that you can download, laminate, and keep in your operatory. In addition, a few simple questions or a sleep self-evaluation tool can be helpful to include in the patient's health history, and having the patient fill out this information prior to the appointment will save you time.

Lastly, it is important to discuss any concerns with the patient and to have a great referral source ready to start them on the journey to a better and healthier quality of life.

An orofacial myologist in your community is a great place to start when referring. This professional will be a licensed dental hygienist or a speech language pathologist who has taken post-graduate education to specialize in treating orofacial disorders. They typically will work as the patient's "case manager" to facilitate further referrals in your community, while working on getting to the root cause of the patient's symptoms. You can find orofacial myologists in your community by doing a simple internet search for "myofunctional therapy near me" or by searching directories such as,, or

By identifying potential sleep-related issues during the hygiene appointment, dental hygienists can provide a more comprehensive approach to their patients' oral health care. Including a sleep risk assessment as part of the hygiene appointment is an important step toward improving the overall health and quality of life of patients.

Kelley Quolas, BSDH, QOM, RDH
Clinical Director
Myofunctional Therapist, My Myo My Health
Phoenix, Arizona


1. American Dental Association. The role of dentistry in the treatment of sleep related breathing disorders: adopted by ADA's 2017 House of Delegates. ADA website. Published 2017. Accessed March 27, 2023.

2. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-143.

3. Stores G. Sleep disorders in children and adolescents. BJPsych Advances. 2015;21(2):124-131.

4. Galeotti A, Gatto R, Caruso S, et al. Effects of rapid palatal expansion on the upper airway space in children with obstructive sleep apnea (OSA): a case-control study. Children (Basel). 2023;10(2):244.

5. Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep. 2015;38(5):669-675.

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