Can Tooth Extractions Cause Sleep Apnea?

At least every few months, I see patients who tell me that after multiple teeth were removed, their health went downhill many months later. I also see many patients with very small mouths who have severe debilitating fatigue and brain fog. Not too surprisingly, they have had 4 to 8 or more extractions when younger. 

Dental extractions are sometimes recommended as standard of care in certain patients who need braces for crooked teeth. As I’ve mentioned before, modern humans have crooked teeth due to our shrinking jaws, leaving less space for our teeth. (Here’s an interview I gave for an orthodontist about the reasons for malocclusion/crooked teeth). So if you take out teeth in a person with a small mouth, will that make the mouth even smaller? And if so, can that cause obstructive sleep apnea?

There are a number of websites that deny that dental extractions can cause sleep apnea, and others that state that their symptoms began after extractions. As you can imagine, this can be a very contentious topic.

I just came back from a very informative conference on orthodontics and obstructive sleep apnea (OSA) at the University of Michigan’s Moyers Symposium. One topic that was discussed was the following: Do dental extractions cause sleep apnea?

The answer from the speaker was a clear no. So I went back to the reference that was cited, all well as numerous other studies on this topic. What I found was very interesting….

This particular study was a retrospective electronic health records review comparing 2792 people with 1 missing premolar in each quadrant with the same number of people without any missing teeth. Of the people without missing premolars, 9.56% had OSA (based on documented sleep studies), whereas 10.71% of those with 4 missing teeth had OSA. There was no statistical significance between the two groups.  They concluded, “The absence of four premolars (one from each quadrant), and therefore a presumed indicator of past “extraction orthodontic treatment,” is not supported as a significant factor in the cause of OSA.”

The authors cite some limitation of this study. First, it’s a retrospective study with all the inherent biases that can affect retrospective (after the fact) studies. Two, it’s estimated that 80 to 90% of people with OSA are not diagnosed. If this is the case, only 10 to 20% of people with OSA were ever picked up in people who had dental extractions. Lastly, missing premolars can result from other causes, such as decay, nongrowth, trauma, or gum disease. It’s also important to note that there was no mention of  timing of OSA or symptoms beginning after extractions.

A handful of radiologic imaging studies found conflicting results. Two studies found that while certain airway dimensions were significantly smaller, airway volume did not change. In another study, subjects who had 4 bicuspid extractions with use of braces to pull back the remaining front teeth had significantly smaller airway space compared to those who underwent extractions only or no extractions. A Chinese study of 30 adults found similar results, showing smaller airway space behind the tongue and a change in the position of the hyoid bone.

In a retrospective review of over 7000 men and women from the National Health and Nutrition Examination Survey from 2005 to 2008, each tooth loss was associated with a 2% higher risk of having OSA based on screening questionnaires. Those who lost 5 to 8 teeth had a 25% higher chance of OSA risk compared to those who lost 1 to 4 teeth, and 36% higher risk for those that lost 9 to 31 teeth, and 61% for people with no teeth. 

In the one study that was performed prospectively using formal in-lab sleep studies, 48 patients who were edentulous (no teeth) underwent sleep studies with and without their dentures. The average AHI was 17 without dentures and 11 with dentures. Another study showed that children with multiple missing teeth had higher levels of AHI.

Many of these patients with VERY small mouths and multiple dental extractions are found not to have obstructive sleep apnea based on sleep studies, but have multiple arousals. The upper airway exam during deep sleep show severe narrowing of the space behind the soft palate or tongue. These patients are usually given various diagnoses such as chronic fatigue syndrome, fibromyalgia, anxiety, depression, irritable bowel syndrome, or have chronic headaches, pain, light-headedness/dizziness, cold hands, or hypersensitivity issues. This is an exaggerated version upper airway resistance syndrome. One possible reason why they don’t have OSA on sleep studies is that when they obstruct, they wake up too quickly to be scored as an apnea. 

As far as I know, there are no prospective, randomized, controlled studies on the effect of extractions measured by pre and post treatment polysomnography. 

So what’s the final judgement? Based on the available evidence, there’s no definitive proof that dental extractions cause sleep apnea, but there’s no proof that it doesn’t either. I think it’s reasonable to say that the fewer the number of extractions, the better. Some extractions are necessary, and not all extractions will lead to airway changes. Also, many of these studies are radiologic studies which measure airway dimensions only, which can’t be correlated to real-life function during sleep, when you’re on your back (or side or tummy) and your muscles are relaxed. 

If you’ve had multiple teeth removed in the past, did you start snoring or develop obstructive sleep apnea months or years later? Please enter your comments in the text box below.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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10 thoughts on “Can Tooth Extractions Cause Sleep Apnea?

  1. I am a dental hygienist and myofunctional therapist with a passion for airway and breathing. Thanks so much for sharing this valuable information and all you do to provide valuable information to everyone. I will be sharing this page with my colleagues.

  2. This describes me quite well. As as young girl I started to develop a very large overbite. Kids in school would tease me calling me a rabbit because my two front teeth stuck out. When I look at photos of myself back then you can see I always looked tired and I was always lethargic. I didn’t smile much back then.

    As a teenager I had 8 teeth extracted in preparation for braces. Some of my wisdom teeth were impacted and the recovery was very painful. Not only did I have braces but I had to wear a headgear. After I had the braces removed I had a nice smile and perfectly straight teeth. I didn’t snore back then – in fact roommates in college always remarked at how quiet I slept but I slept very lightly and woke up easily and frequently.

    My teeth started to become crooked again during my 20s-30s – especially my lower teeth. All my doctors and dentists remark at how small my mouth is. My lower jaw is also receding and I’m getting an overbite again. I had a dentist who recommended that I do braces again but I haven’t. I am now 49 years old and have been diagnosed with severe obstructive sleep apnea. I was prescribed a cpap machine but after a 1 1/2 years of use I cannot tolerate it. I may have to face a tonsillectomy but I am trying to look at other options before resorting to that.

    I just recently learned about oralfacial myofunctional therapy and have started that just 3 weeks ago. I haven’t noticed any results yet and because of my high palate and also a mild tongue tie it is hard for me to do some of the exercises. They also say that it can take a few months before I will notice any results from the therapy.

    I believe that the overbite from my youth might have been caused by incorrect tongue when swallowing/resting. This might have been solved by training tongue position instead of braces. I fear that the multiple tooth extractions plus the use of a headgear caused my mouth to be extremely small and the airway be smaller and more easily blocked by my tongue – which have led to severe OSA. I am also suffering from other health problems such as severe allergies, frequent sinus infections, high blood pressure, hormone imbalances, inability to lose weight – all of which might also be related to years of undiagnosed sleep apnea.

    Thank you for your blog. I find it very interesting. I also recently purchased your book and I look forward to gaining more education as I battle my health issues.

  3. Unfortunately, I can confirm that this does happen as I’ve experienced it myself. After removing two of my wisdom teeth, I noticed that my face felt looser, I started to notice myself drooling in the morning on my pillow. My bite also changed, I couldn’t find a comfortable position for my mouth to sit.

    Appearance wise, I noticed a change a couple of months afterward when looking at photos of myself. My chin looked weaker, my face narrower, my eyes more tired. I always had a broad smile that looked nice in pictures, but after the wisdom teeth removal, my smile wasn’t as wide. I remember smiling for a picture on my birthday that year, and someone saying ‘smile bigger’, as if I wasn’t trying hard enough. I feel like I aged several years in a matter of months after the teeth were removed and my face started to sag.

    Function wise, I think removing them gradually did lead to poorer sleep and less energy. I feel like my personality has changed to some extent as well.

    To visualize, imagine your mouth as a tent and your wisdom teeth as the support beams. Imagine kicking out those support beams – of course, the tent would end up sagging somewhat without the beams propping them up. If your mouth loses its support, there’s less room in airway to breathe which would compromise your quality of sleep.

    Apparently, there are dozens of people that have experienced this as well. Check out the comments from this question posed to a dentist. I don’t quite agree with the dentist’s response on some things, but he does acknowledge that removing wisdom teeth will change your appearance, and he informs his patients before the procedure, considering a part of the informed consent process.
    http://askthedentist.com/can-wisdom-teeth-surgery-cause-a-narrowing-of-the-face/

  4. This is absolutely true for me. There is not one day that pass that I don’t regret getting extraction orthodontic. I had 2 upper premolars 14-24 removed by this absolute lunatic of an orthodontist. I wake up frequently, i has trouble sleeping, obstructed airways. I’m always tired. My health has been downhill since the extractions, so much so that I’m very seriously considering reversing the orthodontic treatment and get 2 implants. I know there are risks to doing that, which I’m absolutely pissed about. Would you be able to comment on the pros and cons of doing this, and the risks for me of getting implants, considering I’m in my early 30s? Thank you and have a great day!

    I also had my wisdom teeth removed as a teen.

  5. V,

    Sorry to hear. What I wrote about was a general concept that suggests that the more teeth you have removed, the more likely there may be health consequences. However, everyone will have different responses. Since everyone is different, I can’t make any specific recommendations for your particular situation without a formal in-person examination. Getting implants may sound like a good option, but there are a number of other considerations that may determine how well you’ll respond, such as how long ago the extractions were done, and the general size and shape of your mouth.

  6. I had 4 molers pulled with braces back in the 70’s. Then around 1980 had 4 wisdom teeth cut out. I have terrible sleep apnea and believe it has lots to do with my now smaller pallet size. There is no room for my tongue to relax when I sleep. In fact even when wide awake I can feel the difference when I barely stick my tongue out. Very bummed out as I haven’t been able to tolerate the CPAP machine or mouth positioner and have heard nothing but nightmare stories about uvula surgery.
    I’m at wits end, actually thought about getting a trach. :(

  7. Dr. Park,

    I removed 8 teeth (4 bicuspids and 4 wisdom) to treat an underbite. I am 11 month in treatment now and I’ve noticed some breathing and sleep problems. I can be 100% sure what’s causing it, I hope it is allergy that is causing these. I am scared now, do you know a solution to this?

    Thank you

  8. I had crooked canines as a teenager so I had teeth pulled to have the push up braces put in. When the treatment finished the teeth were better but not perfectly straight.

    In my 40s I was having pain chewing with my left molars. An x ray revealed impacted wisdom teeth & dentist advised me to remove. He also pulled out the back left molar after he took the wisdom teeth out as it was a little decayed. The wisdom teeth were deep & resulted in him cutting part of the jaw. This has resulted in a smaller jaw on one side and a very assymetrical smile with the nose looking more crooked on left side.

    I was also diagnosed with moderate sleep apnea shortly after this and use CPAP.

    Recently I also had left back bottom molar pulled out too as it was decayed & damaging molar next to it.

    In my mid 40s I went to see a cosmetic dentist to see if I could have molar implants on left side to fill out that side of the face and restore aesthetics. The cosmetic dentist said I have hardly any bone left for implant as it was removed during left side wisdom teeth surgery. The dentist says that I have to live with the assymetry and that my face will collapse further on left side as I get older as there is no molar support. He has also said that using CPAP will also cause facial changes.

    He has advised me to get Invisalign to straighten teeth properly and push the molars on the left side back a bit more to provide some support.

    However I am fearful that invisalign treatment and moving my teeth around at my age may cause more facial changes and further bone loss.

    Any advise as to whether I leave the teeth alone or straighten them all out???

  9. I can not sleep on my back without waking up out of breath. I had 6 teeth pulled out during braces.