Oral manifestations in children with sleep disorders

Pages: 24-39

Ahu Durhan (1), Francois Clauss (2), Işıl Özgül Kalyoncu (3), Ameerah Suleiman (1), Raghda Gadaou (1), Betul Kargul (1)

(1) Department of Pediatric Dentistry, Dental School, Marmara University, Istanbul, Turkey;(2) Department of Pediatric Dentistry, Faculty of Dental Surgery, University of Strasbourg, CSERD of Strasbourg, Strasbourg, France;(3) Department of Pediatric Dentistry, Eastern Mediterranean University, Faculty of Dentistry, Famagusta, North Cyprus* Corresponding author: Betul Kargul kargulbetul@gmail.com


Oral health assessment is performed by dentists to identify oral health problems and diseases. Oral health is a mirror of general health and one of the systemic health issues that directly affects the oral cavity is sleeping disorder. Sleep is a fundamental process of the human body, which regulates core biological functions. Sleep quality reflects a person’s ability to fall asleep, stay asleep, and enter into the various rejuvenating sleep cycles for the full duration. People with sleep disorders have various problems, including oral and systemic conditions and altered quality of life. Obstructive sleep apnea, which has historically been considered an adult male disease, is being recognized more often. Research suggests that various oral malformations found in newborns and young children can manifest as obstructive sleep apnea in children. Dentists may be the first healthcare providers who can identify sleeping disorders during oral health assessment and make referrals to professional healthcare providers to obtain proper treatment.

Key words: sleep disorders, obstructive sleep apnea, oral dental health


Sleep is defined as a readily reversible suspension of sensorimotor interactions with the environment, usually associated with recumbence and immobility. Sleeping is really important for each human body because we got our energy and physical strength from it. Sleep is important for children’s general health and keeps them active during the day in school with a lot of focus and high learning performance [1]. Sleeping is an active physiological process and there are a lot of side effects related to sleep deficiency that impacts daytime functioning, including daytime behavioral problems (hyperactivity, aggressive behavior and impulsivity). It may cause fatigue and daytime lethargy, headaches, mood disturbance (such as irritability, emotional disturbance, depression and anger), cognitive impairment (problems with memory, attention, concentration, decision making, and problem-solving), and the use of stimulants such as caffeine and nicotine in adolescents [2].

Sleep-related disorders constitute a spectrum of clinical entities with variations in sleep structure, breathing and blood oxygen saturation. Sleep disorders are a group of disorders varying from mild snoring to severe obstructive sleep apnea (OSA) [3].

In recent years sleeping disorders were noticed in about 25% of children [4]. Some studies have found that 3.7% of children are diagnosed with sleeping disorders while 6.1% take medications for it [5]. Also, a national survey found that 34% of adolescents reported having sleep difficulties for at least 2 weeks [6]. Sleep problems are more common associated with comorbidities such as psychiatric illnesses (eg, depression or anxiety), medical comorbidities such as asthma, autism spectrum disorder (ASD), other neurodevelopmental disorders [7], attention-deficit hyperactivity disorder (ADHD) and atopic dermatitis [8].

Sleep Development

2 types of sleep occur during sleep and each type of them has different levels of brain activity, muscle tone and autonomic response: 1 – Non Rapid Eye Movement (NREM) and 2 – Rapid Eye Movement (REM).

According to electroencephalographic changes, the first type of sleep (NREM) consists of 4 stages which are completed at 6 months of age: stage 1 is the lightest sleep and stage 4 is the deepest sleep.

Stage 1: it occurs at the beginning of the sleep period, represents 2-5% of total sleep period, with a reduction in body movement and response.

Stage 2: is the true stage of the sleep period. It is about one half of total sleep period with the majority happening in the middle of the night. During this stage there are reduced muscle tone, decrease eye movement and deceleration of respiration and heart rate.

Stage 3-4: There are close together and they are called deep sleep or slow-wave sleep. They occur in the early hours of sleep period and represent 20% of total sleep period. During these stages slow breathing, decreased heart rate and relaxed body are noticed.

The second type of sleep is Rapid Eye Movement (REM) sleep which reflects what the brain usually learns during the day. Its percentage is high in the infant (about 55%) but decreases in 5 years of age to 20-25%. It is characterized by muscle paralysis, rapid eye movements with facial expressions depending on the dream that is present [9].

Key features of sleep in childhood

The most dramatic evolution in sleep takes place within the first 12 months of life, but sleep continues to evolve over a lifetime as a physiologic process. Sleeping times are different from child to child but it is longer in infants and decreases with age (Table I). [10].

AgeTotal sleep time
4 to 12 months12 to 16 hours a day
1 to 2 years11 to 14 hours a day
3 to 5 years10 to 13 hours a day
6 to 12 years9 to 12 hours a day
13 to 18 years8 to 10 hours a day
Table I. The average sleep needs according to age (adapted from Paruthi et al., 2016 [10])

Sleep disorders, oral health and oral function

Improving sleep quality and sleep characteristics, oral health and oral function involves both pathophysiology and disease management. Sleep disorders can be influenced by craniofacial morphology and can affect oral health. Thus, modifying the maxillofacial structure and oral function can help in the management of sleep disorders [12]. Dentists always examine the oral cavity to investigate and diagnose any oral diseases. The oral cavity is the mirror of the body. Sleep is a fundamental process of the human body, which regulates core biological functions. Sleep quality reflects a person’s ability to fall asleep, stay asleep and enter into the various rejuvenating sleep cycles for the full duration. A person who does not obtain quality sleep can exhibit a wide range of oral, systemic and cognitive health problems. Dentists are the health care professionals who are responsible to detect sleeping disorders through the oral cavity. If the dentist detects any oral signs that are related to sleeping disorders issues according to the American Dental Association, he must refer at-risk patients to an appropriate medical doctor (e.g., otolaryngologist, pulmonologist, sleep medicine physician) and communicate with them to determine the best treatment options to that patient [13].

Obtaining health history

During routine oral health assessments visits, dentists obtain a complete medical history of their patients. Dentists obtain a complete and accurate medical history asking patients about medical conditions and the medicines that they are using. Medical conditions such as diabetes mellitus, heart problems, blood diseases, mental disabilities, cognitive and behavioral conditions must be known to the dentists because every one of these conditions can affect the oral cavity and the way of treatment that the dentist provides. During obtaining the medical history dentists also must ask about sleep problems history if existed and other questions about sleep which include:

  • Does your child snore loudly when sleeping?
  • Does your child stop breathing during sleep?
  • Is your child hard to wake up in the morning?
  • How many hours does your child sleep daily?
  • Does your child tend to breathe through his/her mouth during the day?
  • Does your child fall asleep quickly?

Dentists also must ask about the patient’s dental history including questions about previous dental experiences and current dental problems because if there is a history of dry mouth, mouth breathing, periodontal problems, orthodontic treatments, teeth clenching or high caries experience could indicate the presence of sleeping disorders problems [14].

Extraoral examination

Dentists always perform extraoral examinations on all patients during all dental visits. The extraoral examinations include comparing both sides of the face to detect any differences between right and left sides, examining the face completely including the nose (nasal bridge, dorsum, ala and the apex), eyes (eyelids, eyebrows and the eyelashes), skin (color, hairs, any exciting lesions-scares or acne), neck (palpate and touch the lymph nodes), forehead, the mouth (vermilion borders, commissure and the philtrum). Some signs may alert the dentists that the patient is have sleeping disorders or is susceptible to them such as dry lips, an open mouth and a long and narrow face [15].

Intraoral examination

Dentists always perform an intraoral examination for all patients during all dental visits. The intraoral examinations include examination of soft tissues: gingiva, tongue (dorsal, ventral and lateral surfaces), mucosa, soft palate muco-buccal fold, oropharynx, uvula and hard tissues: hard palate, tuberosity/hamular notch, retromolar pad area. Teeth examination is performed to detect caries, previous restorations, broken and missing teeth. Periodontal examination is performed to detect bleeding on probing, attachment loss and bone loss. Radiographs are taken when needed to confirm the examinations such as bitewing radiographs to detect caries, panorama radiographs to detect the development of the teeth, loss of the bone and cephalometric radiographs to identify the malocclusions [16]. Some signs may alert the dentists that the patient is having sleeping disorders such as Class II malocclusion, periodontal problem, narrow palate and open bite.

Recently, OSA in children has public attention and now it is considered one of the most common diseases in children so there is focusing on this disease from the researches area.

Obstructive sleep apnea

OSA is a chronic multifactorial respiratory disease. It consists of a temporary decline or cessation of breath for ≥ 10 seconds. It often leads to a reduction in oxygen saturation levels in the blood of more than 3% to 4% and or neurological arousal [17-19].

Prevalence of pediatric sleep apnea

OSA in children is one of the most common sleep disorders. Approximately 7 to 9 million children (representing 1-4% of all children) had OSA and this number is really big. For this reason, health care providers should start to warn the families and make an essential diagnosis for every child that come to dental clinic to start early treatment and avoid the future consequences. According to the American Academy of Pediatric Dentistry (AAPD), signs of untreated OSA in school-aged children can include neurocognitive dysfunction such as aggressive behavior, symptoms that resemble attention deficit hyperactivity disorder (ADHD), learning deficits, deteriorating school performance, bedwetting, growth retardation and reduced quality of life [20].

Obstructive Sleep Apnea and the Oral Cavity

Oral health is a reflection of systemic health. The manifestation of several systemic diseases emerges in the oral cavity and the same applies to OSA as well [19]. Sleep disorders have the following oral manifestations: gingivitis, periodontitis, dry mouth, halitosis, frequent throat infections, etc. A thorough examination and history are important in the diagnosis. One of the diagnosis methods to detect OSA is Mallampati’s classification of soft palate and uvula. It was proposed to predict the chances of developing OSA and thus it can be use as a guide to diagnosing respiratory diseases as well as for pre-anesthetic evaluation for patients undergoing procedures under general anesthesia and may require intubation [21] .

The second type of diagnosis method is Positive Air Pressure which was introduced by Professor Colin Sullivan. He advocated for dentists to be part of the health care team and play an important role in the diagnosis and management of OSA in four areas [22].

1. Treatment of snoring and moderate OSA.

2. Identifying at-risk children and adults by examining their upper airways on periodic visits.

3. Avoiding deleterious orthodontic treatments and treating pediatric patients with rapid maxillary expansion.

4. Anticipating the need for bimaxillary osteotomy in young adults requiring maxillofacial correction.

Open-mouth breathing and tongue placement are directly related to the formation of the maxilla, sinuses, nasal cavity and palate. The formation of the oral structures has a direct effect on the ability to breathe, chew and swallow properly [23].

Clinical Signs and Symptoms

· Bruxism is the first sign of sleep apnea [24].

· Clenching can cause regressive alteration of the tooth structure and breakage as well as inflamed and receding gingiva and an increase in the number of carious teeth because of the force damages [24].

· Attrition of the teeth because of repeatedly moving the mandible forward (which is a protective mechanism of the body because the position of the tongue posteriorly leads to a reduction in the airway space) and with time this leads to excessive strain over the temporomandibular joint (TMJ) which cause temporomandibular joint disorders (TMD) [25].

 · Mobility of anterior teeth comes from trauma from occlusion but it is also dependable on the patient’s health and periodontal tissues [23].

 · Excessive bone loss could be local or diffuse in patients with periodontitis in the areas of mobility [23].

· Tongue crenulations (i.e., scalloped borders) suggest that the patient is depressing the tongue forward against the mandibular teeth regularly to open the oral airway [23].

· An anterior or lateral open bite may happen according to the position of the tongue [23].

· Dimpling of the functional cusps and lingual or palatal surfaces of the dentition can indicate related gastroesophageal reflux disorder [23].

·Tongue-tie (ankyloglossia) which restricts the tongue’s range of motion is associated with narrow maxillary inter-canine and intra-molar width resulting in a high narrow hard palate [23].

• Enlarged tonsils and tongue (Macroglossia). The Freidman Staging System, which is often used in medical settings to assess airway, is a useful tool to provide a measurable anatomic description to document obstruction. This system classifies tongue position and tonsil size according to anatomical features visualized when the mouth is open and relaxed. A resting tongue position that covers the mandibular teeth and prevents visualization of the entire oropharynx and soft palate is likely to be contributing to significant airway obstruction(Class 3 and 4 scores suggest crowding in the pharyngeal region making it difficult to breathe while sleeping when the tongue collapse posteriorly [23].

• Malocclusion. Angle’s Class II malocclusion, facial profile and narrow maxillary arch are related to each other. Class II malocclusion is more likely to cause a convex facial profile and a narrow maxillary arch. The narrow maxillary arch may reduce the upper airway space leading to an increased risk of difficulty in breathing due to collapsed tongue along with reduced tongue space which further contributes to the risk of developing OSA [23].

Other features include:

· The development of orofacial pain

· A reduced jaw size

· Erythema in the larynx and/or pharynx (caused by snoring and mouth breathing, which are another symptoms of sleep apnea)[23].

• Certain factors that contribute to OSA such as older age, male gender, smoking status and mouth breathing may also contribute to periodontal disease [26].

Obstructive Sleep Apnea and Periodontal Health

The association between both diseases has been proposed by numerous theories.

1. Oral breathing frequently leads to desiccation of the mucous membranes of individuals with OSA (due to oral breathing or the pharmacological effects of hypotensive drugs), which enables the periodontal microbiota for greater colonization.

2. Both OSA and periodontitis are associated with the presence of systemic inflammation.

3. Both diseases are related to oxidative stress.

4. OSA shares common risk factors and comorbidities as that periodontitis. The evidence that inflammatory mediators play a role in the pathogenesis of OSA and periodontitis and the fact that they both share the same risk factors suggest a potential association between the two conditions [27].

Obstructive Sleep Apnea in Children with Down syndrome

Down syndrome (DS) also called trisomy 21 because it happens due to the presence of a third copy of chromosome 21 (full or partial), is a genetic disorder and it is considered the most common chromosomal disorder in live-born children. Approximately one in every 700 born children has DS. According to many studies, these children are usually born with several physical and mental problems. Also, they are at risk to develop more diseases during their life. One of these diseases is OSA. Approximately 30-60% of DS children have sleep apnea. OSA in children with DS is often a complex and multifactorial condition due to a combination of predisposing risk factors to develop airway obstruction [28].

Factors contributing to OSA in children with DS:

  1. Midface
  2. Maxillary and mandibular hypoplasia
  3. Narrow nasopharynx, relative macroglossia (due to crowding of the oropharynx)
  4. Adenotonsillar hypertrophy
  5. Shortened palate
  6. Generalized hypotonia
  7. Immature immune system (more respiratory infections)
  8. Thyroid dysfunction
  9. Obesity[29].

Oral and dental symptoms include: dry mouth, bad breath, gingival bleeding, gingival swelling, sensations of soreness and burning, difficulties in speaking, chewing, and swallowing, mucosal atrophy and an altered oral microflora. Moreover, a significantly higher prevalence of enamel demineralization, dentinal sensitivity, progressive dental caries, as well as periodontal disease are reported in patients with chronic dry mouth[29].


Good sleep is important to oral and systemic health and proper treatment of sleeping disorders problem it needed. Dentists must be able to identify these problems from the oral health assessment by obtaining patients’ systemic and oral health history, proper diagnosis, and providing additional assessments, such as administering a sleep quality questionnaire and then referring the patient to an appropriate health care professional. There is a strong relationship between systemic health and oral health so the dentist’s job is not only to obtain optimal oral health but also to obtain optimal general health by identifying problems and referring the patients to professional health care providers when it needs.

FUNDING/SUPPORT: This study is partly supported by ERASMUS + Project OSCAR 2019-1-RO01-KA202-063820


  1. Bathory E, Tomopoulos S. Sleep regulation, physiology, and development sleep duration and patterns and sleep hygiene in infants, toddlers, and preschool-age children. Curr Probl Pediatr Adolesc Health Care 2017;47(2):29–42.
  2. Trosman I, Ivanenko A. Classification and Epidemiology of Sleep Disorders in Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2021;30(1):47-64.
  3. Mokhlesi B. Obesity hypoventilation syndrome: a state-of-the-art review. Respir Care 2010;55(10): 1347-1362.
  4. Owens J. Classification and epidemiology of childhood sleep disorders. Sleep Med Clin 2007;2(3):353-361. 
  5. Meltzer LJ, Johnson C, Crosette J, Ramos M, Mindell JA. Prevalence of diagnosed sleep disorders in pediatric primary care practices. Pediatrics 2010;125(6):e1410-e1418.
  6. Blank M, Zhang J, Lamers F, Taylor AD, Hickie IB, Merikangas KR. Health correlates of insomnia symptoms and comorbid mental disorders in a nationally representative sample of US adolescents. Sleep 2015;38(2):197-204. 
  7. Robinson-Shelton A, Malow BA. Sleep disturbances in neurodevelopmental disorders. Curr Psychiatry Rep 2016;18(1):6.
  8. Chang YS, Chiang BL. Mechanism of sleep disturbance in children with atopic dermatitis and the role of the circadian rhythm and melatonin. Int J Mol Sci 2016;17(4):462.
  9. El Shakankiry HM. Sleep physiology and sleep disorders in childhood. Nat Sci Sleep 2011; 3: 101–114.
  10. Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med 2016;12(6):785–786.
  11. https://doi.org/10.1016/j.chc.2020.08.002.
  12. Sánchez T, Castro-Rodríguez JA, Brockmann PE. Sleep-disordered breathing in children with asthma: a systematic review on the impact of treatment. J Asthma Allergy 2016; 9:83–91. 10.2147/JAA.S85624.
  13. Huynh NT, Emami E, Helman JI, Chervin RD. Interactions between sleep disorders and oral diseases. Oral Diseases 2014;20:236–245.
  14. American Dental Association. Council on Dental Practice – Dentistry’s Role sleep – Related Breathing Disorders. Available at: https://www.ada.org/en/member-center/leadership-governance/councils-commissions-andcommittees/dentistry-role-in-sleep-related-breathingdisorders (accessed March 20, 2019).
  15. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice Revised 2016 Supplement.pdf (accessed March 20, 2019).
  16. Guilleminault C, Huang YS. From oral-facial dysfunction to dysmorphism and the onset of pediatric OSA. Sleep Med Rev 2018; 40:203–214.
  17. Ahmad NE, Sanders AE, Sheats R, Brame JL, Essick GK. Obstructive sleep apnea in association with periodontitis: a case-control study. J Dent Hyg 2013;87(4):188 -199.
  18. Loke W, Girvan T, Ingmundson P, Verrett R, Schoolfield J, Mealey BL. Investigating the association between obstructive sleep apnea and periodontitis. J Periodontol 2015;86(2):232-243.
  19. Nizam N, Basoglu OK, Tasbakan MS, Lappin DF, Buduneli N. Is there an association between obstructive sleep apnea syndrome and periodontal inflammation? Clin Oral Investig 2016;20(4):659-668.
  20. Stauffer J, Okuji DM, Lichty II GC, Bhattacharjee R, Whyte F, Miller D, Hussain J. A review of pediatric obstructive sleep apnea and the role of the dentist. J Dent Sleep Med 2018;5(4):111-130.
  21. Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC, Hamilton GS, Dharmage SC. Prevalence of obstructive sleep apnea in the general population: a systematic review. Sleep medicine reviews 2017;34:70-81.
  22. Kendzerska T, Mollayeva T, Gershon AS, Leung RS, Hawker G, Tomlinson G. Untreated obstructive sleep apnea and the risk for serious long-term adverse outcomes: a systematic review. Sleep Med Rev 2014;18(1):49-59.
  23. Padmanabhan AK, Gautam RS, Paramashiviah R, Prabhuji MLV. Obstructive sleep apnea and oral health: a short review. International Journal of Current Medical and Pharmaceutical Research 2019;5(10): 4601-4606.
  24. Lee SY, Guilleminault C, Chiu HY, Sullivan SS. Mouth breathing, “nasal disuse,” and pediatric sleep-disordered breathing. Sleep Breath 2015;19(4):1257–1264.
  25. Balasubramaniam R, Klasser GD, Cistulli PA, Lavigne GJ. The Link between Sleep Bruxism, Sleep Disordered Breathing, and Temporomandibular Disorders: An Evidence-based Review. J Dent Sleep Med 2014;1(1):27–37.
  26. Seo WH, Cho ER, Thomas RJ, An SY, Ryu JJ, Kim H, Shin C. The association between periodontitis and obstructive sleep apnea: a preliminary study. J Periodontal Res 2013;48(4):500-506.
  27. Al-Jewair TS, Al-Jasser R, Almas K. Periodontitis and obstructive sleep apnea’s bidirectional relationship: A systematic review and meta-analysis. Sleep Breath 2015;19:1111-1120.
  28. Maris M, Verhulst S, Wojciechowski M, Van de Heyning P, Boudewyns A. Prevalence of Obstructive Sleep Apnea in Children with Down syndrome. Sleep 2016; 39(3): 699–704.
  29. Durhan MA, Agrali OB, Kiyan E, Ikizoglu NB, Ersu R, Tanboga I. Does obstructive sleep apnea affect oral and periodontal health in children with Down syndrome? A preliminary study. Niger J Clin Pract 2019;22(9):1175-1179.

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