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.