The Adult Airway, Sleep, and the Oral Microbiome

October 24, 2022

By John C Comisi, DDS, MAGD, Associate Professor, Medical University of South Carolina, James B. Edwards College of Dental Medicine

Poor sleep can affect overall health, including your oral health.

Sleep Related Breathing Disorders (SRBDs) have become more and more written and talked about in recent years. It’s almost as if a light went on in the health care arena recognizing that how well we sleep may contribute to the wellness of a person.

The mattress, pillow and pharmaceutical companies certainly have been keenly aware of this for years and have emphasized this in their commercial advertisements. Yet, the underlying medical component of poor sleep seems to have evaded the medical community for quite some time. The understanding that this problem is a disease only recently seems to be gaining traction.

A disease, as defined by the Oxford Languages Dictionary, is “a disorder of structure or function in a human, animal or plant, especially one that produces specific signs or symptoms or affect a specific location and is not simply a direct result of physical injury”.

We have all experienced in our lives those individuals who, once they fall asleep, commence to snore. Our parents did it, other family members did it, friends did it and it was either cute or overwhelmingly disruptive to a good night’s sleep for those around the culprit.  

The surprising and serious links between sleep, snoring and stroke have become more apparent in literature. A recent paper by Bonsignore, et al[i] outlined the common comorbidities of Obstructive Sleep Apnea (OSA) patients, including cerebrovascular diseases, systemic hypertension, cardiovascular events and/or death, arrythmias, metabolic diseases (MetS), diabetes, obesity, renal disease, COPD, asthma, and cancer.

The article discusses Metabolic Diseases which are of significant interest in that they are a “pre-diabetic state associated with central obesity and increased cardiovascular risk” and are “highly prevalent in OSA patients, and according to some authors, OSA should be considered as an additional manifestation of MetS”.

Growth and development has also been a keen area of investigation, since SRBD in children designates a wide spectrum of respiratory disorders characterized by partial or complete obstruction of the upper airway.[ii] The manifestations of OSA in children cannot be overemphasized and every health care provider should be on the lookout for the classic signs and symptoms. The open mouth’s posture, the long recessive chin, no spacing between primary teeth, snoring and loud breathing, grinding of teeth are some of the classic signs to look for in children. It is incumbent on physicians and dentists to be on the lookout for these signs to help, with early interception, potentially alleviate significant problems as these children grow into adulthood.

If there is no intervention, then the physical and physiologic will likely develop. The most common symptoms: snoring, excessive daytime sleepiness and hypertension. Unfortunately, many in the health care arena, may overlook these and merely treat the symptoms without identifying the underlying problem.

The role of the dentist has been redefined and every patient consulting a dental practice is not merely a dental patient, he/she also requires a comprehensive medical review.[iii] This is a collaborative evaluation and treatment process. The dental professional cannot render a diagnosis of SRBD, but they can and should play an active role in the screening and referral mechanism to determine the underlying medical problem and, once a diagnosis is rendered, become a valuable part of the team helping the patient. Dentists also play an important role in evaluating patients with OSA for the suitability of oral appliance therapy.[iv]

In 2017 the American Dental Association (ADA) House of Delegates adopted a policy statement on The Role of Dentistry in the Treatment of Sleep Related Breathing Disorders.[v] In that policy statement the ADA stated that “Dentists can and do play an essential role in the multidisciplinary care of patients with certain sleep-related breathing disorders and are well positioned to identify patients are greater risk of SRBD”. Additionally, the American Academy of Sleep Medicine’s Practice Parameters[vi] emphasize this important interrelationship between medicine and dentistry and how oral appliance therapy is a valuable component of care for those patients diagnosed with obstructive sleep apnea.

Recognizing this, we must also move to an understanding on how SRBD and OSA can significantly affect the oral environment. Patients that suffer with untreated OSA routinely breath through their mouths. This creates an environment that is not conducive to proper skeletal development as a child grows nor a healthy oral microbiome, which can lead to arenas that encourage caries development and periodontal disease.[vii] Wu, et al, identified that the nasal microbiome has also been shown to be altered by OSA.[viii] According to this study, “the microbes identified as associated with severe OSA were frequently human oral commensals, such as Streptococcus, Prevotella, Veillonella and Porphyromonas. We know that nasal breathing is important in the creation of the vasodilator, nitric oxide, which is primarily created via nasal breathing. If, as suggested by Wu, et al, that the nasal mucociliary system is significantly deteriorated in patients with severe OSA, the well-being of the patient is going to fail over time, since effective filtration of air breath in by the patient and the ability to create the important vasodilator to help with systemic oxygenation is diminished, and as such illness can progress and possibly accelerate.

In the paper, Analysis of oral microbiota in patients with obstructive sleep apnea-associated hypertension[ix], Ko, et al. demonstrate a predictive function of oral microbiota was different in patients with OSA with or without hypertension (HTN). Again, Porphyromonas along with Aggregatibacter were found in abundance. Another paper by Chen et al.[x] also concluded the noninvasive biomarkers for patients with OSA and hypertension. They found the relative abundance of the genus Actinomyces was significantly decreased in patient with hypertension compared with healthy controls, bacterial genera Haemophilus, Neisseria, and Lautropia were enriched in HTN and Oribacterium was found to be a unique taxa in the OSA comorbid HTN group compared with the control group.

From the evidence presented, one might ask did the OSA create the change in the oral microbiota? Or perhaps was it the change in the oral microbiota that caused the OSA? Perhaps what’s at play here is the individual epigenetic of an individual’s makeup could create a predisposition toward OSA development due to mouth breathing, thereby creating an overabundance of microbial change which then contributes to the development of OSA. Whatever the causality, those that suffer from OSA have an oral microbiome challenge.

The healthy commensals needed to maintain a balanced oral environment are overwhelmed and enables the overpopulation of those unhealthy microbes.[xi] There is a need to replenish the beneficial bacteria in those suspected of or diagnosed with OSA. The benefit of using an oral probiotic daily has been documented for some time for the ability to rebalance the oral biome and therefore to reduce the colony forming unit (CFU) counts of oral parthenogens.[xii]^,[xiii] By increasing the healthy bacteria in the mouth, oral-care probiotics have the potential to manage multifactorial diseases including periodontal disease and caries, by effecting the host-microbial interface and restoring homeostasis which may not be achievable with other interventions.[xiv] It can then be surmised that we should consider the incorporation of an oral-care probiotic into the care regimen of the patients we treat, not only for the management of caries and periodontal disease, but also for those patients we suspect have, or are diagnosed with, a sleep-related breathing disorder. It potentially could be an important adjunct, not only in maintaining the oral health of the individual, but also in maintaining the systemic health as well

[i] Bonsignore, M.R., Baiamonte, P., Mazzuca, E. et al. Obstructive sleep apnea and comorbidities: a dangerous liaison. Multidiscip Respir Med 14, 8 (2019). https://doi.org/10.1186/s40248-019-0172-9

[ii] Luzzi V, Ierardo G, Di Carlo G, Saccucci M, Polimeni A. Obstructive sleep apnea syndrome in the pediatric age: the role of the dentist. Eur Rev Med Pharmacol Sci. 2019 Mar;23(1 Suppl):9-14. doi: 10.26355/eurrev_201903_17341. PMID: 30920636.

[iii] Hafiz M. Moin Anwer, Hamad N. Albagieh, Mythili Kalladka, Harmeet K. Chiang, Shaima Malik, Sean W. McLaren, Junad Khan. The role of the dentist in the diagnosis and management of pediatric obstructive sleep apnea. The Saudi Dental Journal, Volume 33, Issue 7, 2021, Pages 424-433, ISSN 1013-9052, https://doi.org/10.1016/j.sdentj.2021.02.001.

[iv] Quan SF, Schmidt-Nowara W. The Role of Dentists in the Diagnosis and Treatment of Obstructive Sleep Apnea: Consensus and Controversy. J Clin Sleep Med. 2017 Oct 15;13(10):1117-1119. doi: 10.5664/jcsm.6748. PMID: 28942761; PMCID: PMC5612624.

[v] https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/the-role-of-dentistry-in-sleep-related-breathing-disorders.pdf

[vi] Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. 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 Jul 15;11(7):773-827. doi: 10.5664/jcsm.4858. PMID: 26094920; PMCID: PMC4481062.

[vii] Sotozono M, Kuriki N, Asahi Y, Noiri Y, Hayashi M, et al. (2021) Impact of sleep on the microbiome of oral biofilms. PLOS ONE 16(12): e0259850.https://doi.org/10.1371/journal.pone.0259850

[viii] Wu BG, Sulaiman I, Wang J, Shen N, Clemente JC, Li Y, Laumbach RJ, Lu SE, Udasin I, Le-Hoang O, Perez A, Alimokhtari S, Black K, Plietz M, Twumasi A, Sanders H, Malecha P, Kapoor B, Scaglione BD, Wang A, Blazoski C, Weiden MD, Rapoport DM, Harrison D, Chitkara N, Vicente E, Marin JM, Sunderram J, Ayappa I, Segal LN. Severe Obstructive Sleep Apnea Is Associated with Alterations in the Nasal Microbiome and an Increase in Inflammation. Am J Respir Crit Care Med. 2019 Jan 1;199(1):99-109. doi: 10.1164/rccm.201801-0119OC. PMID: 29969291; PMCID: PMC6353011.

[ix] Ko CY, Hu AK, Chou D, Huang LM, Su HZ, Yan FR, Zhang XB, Zhang HP, Zeng YM. Analysis of oral microbiota in patients with obstructive sleep apnea-associated hypertension. Hypertens Res. 2019 Nov;42(11):1692-1700. doi: 10.1038/s41440-019-0260-4. Epub 2019 Apr 11. PMID: 30976074; PMCID: PMC8075895.

[x] Chen X, Chen Y, Feng M, Huang X, Li C, Han F, Zhang Q, Gao X. Altered Salivary Microbiota in Patients with Obstructive Sleep Apnea Comorbid Hypertension. Nat Sci Sleep. 2022 Apr 8;14:593-607. doi: 10.2147/NSS.S347630. PMID: 35422668; PMCID: PMC9005082.

[xi] Cai Y, Juszczak HM, Cope EK, Goldberg AN. The microbiome in obstructive sleep apnea. Sleep. 2021 Aug 13;44(8):zsab061. doi: 10.1093/sleep/zsab061. PMID: 33705556.

[xii] Laleman I, Teughels W. Probiotics in the dental practice: a review. Quintessence Int. 2015 Mar;46(3):255-64. doi: 10.3290/j.qi.a33182. PMID: 25485319.

[xiii] Seminario-Amez M, López-López J, Estrugo-Devesa A, Ayuso-Montero R, Jané-Salas E. Probiotics and oral health: A systematic review. Med Oral Patol Oral Cir Bucal. 2017 May 1;22(3):e282-e288. doi: 10.4317/medoral.21494. PMID: 28390121; PMCID: PMC5432076.

[xiv] Allaker RP, Stephen AS. Use of Probiotics and Oral Health. Curr Oral Health Rep. 2017;4(4):309-318. doi: 10.1007/s40496-017-0159-6. Epub 2017 Oct 19. PMID: 29201598; PMCID: PMC5688201.