Original Article 1, Issue 13.2
Using Dental Acidic Erosion to Screen for Obstructive Sleep Apnea: A Cross-Sectional Pilot Study
http://dx.doi.org/10.15331/jdsm.7430Pamela J. Fulton, DHSc1; Jeffrey L. Alexander, PhD1
1Doctor of Health Sciences Program, College of Graduate Health Studies, A.T. Still University, Kirksville, Missouri, USA
ABSTRACT
Study Objectives:
The purpose of this cross-sectional pilot study was to describe how a small sample of Texas dentists use dental acidic erosion to screen for obstructive sleep apnea (OSA).
Methods:
A descriptive, cross-sectional survey design was used. Participants were recruited from the Central Texas Dental Society to complete an anonymous 20-question online survey. Licensed general dentists were eligible for participation. The survey contained 3 demographic questions, 11 questions on OSA, and 6 questions about dental acidic erosion. The response type varied between 14 dichotomous (yes, no) responses, 1 dichotomous (yes, no, unsure) response, 3 Likert-like responses, 1 multiple-choice response, and 1 fill-in-the-blank response.
Results:
A total of 30 Texas dentists participated; however, 2 non-general dentists were excluded. The mean (SD) number of practice years was 20.9 (13.9); range, 2 to 47 years. Most participants (23 of 26, 88.5%) indicated they had received no OSA screening instruction in their dental curriculum. More than half did not routinely screen for OSA (15 of 26, 53.6%) or think erosion was important for screening (14 of 26, 53.8%). No participants reported using a screening tool that included erosion as a factor.
Conclusion:
Our results suggest limited dental education and the absence of erosion in screening tools may be impeding screening for OSA.
Clinical Implications:
Study findings suggest future research is needed on dental erosion and its link with OSA for dental training and education. The development of a comprehensive screening tool inclusive of dental acidic erosion observation is warranted.
Keywords:
dental wear, dental exam, sleep apnea screening, dental education
Citation:
Fulton PJ, Alexander JL. Using Dental Acidic Erosion to Screen for Obstructive Sleep Apnea: A Cross-Sectional Pilot Study. J Dent Sleep Med. 2026;13(2).
INTRODUCTION
Approximately one billion people worldwide are affected by obstructive sleep apnea (OSA).1-4 This sleep disorder involves repeated obstruction of breathing during sleep and is often undiagnosed.1-4 Health problems associated with OSA include orofacial pain from bruxism, anxiety, depression, cancer, restless leg syndrome, neurodegenerative disorders, high blood pressure, and weight gain.5 OSA has also been associated with an increase in nightmares,4 which negatively affects quality of life, and with gastroesophageal reflux disease (GERD).4, 6-11 In the dental clinic, the acidic effects of GERD can be seen as erosion of the dentition.12-19 Despite the negative effects of OSA, approximately 75% of the general population is unaware of OSA and its resulting health risks.3, 20-24 Better methods of early diagnosis are necessary for successful treatment.
Although recognizing the clinical signs of OSA, such as dental acidic erosion, should be part of an evidence-based dental practice, research suggests appropriate education and screening protocols are often lacking.25, 26 Given the relationship between OSA and GERD and between GERD and dental acidic erosion, better recognition of the relationship between dental acidic erosion and OSA is needed. Multiple authors have stressed the importance of detection, diagnosis, and treatment for OSA;1-7, 10-12, 20-23, 25-31 however, there is limited research directly linking dental erosion and OSA.12, 18 Instead, a multifaceted approach seems to connect dental erosion and OSA. For example, GERD exposes the teeth to gastric acid,5-11, 16-18 which results in a loss of enamel texture and cupping or flattening of the occlusal surfaces.12, 31 Clinically visible evidence of this erosion during a dental clinical examination should be part of the screening process for OSA, especially because early detection of OSA by dental providers may lead to better patient outcomes. However, to the authors’ knowledge, no studies have investigated the use of dental acidic erosion for screening purposes. Furthermore, research suggests public health professionals lack awareness of OSA, which highlights a need for improved screening tools and increased education and practice with those tools.5, 25, 26, 29, 30
Despite the importance of screening for OSA, there is scant information describing how dental professionals can include dental acidic erosion as part of the screening process for OSA. Currently, comprehensive and periodic dental examinations focus on more than just caries; they are also intended to identify oral abnormalities, such as cancerous lesions,32 and dental and gingival inflammatory responses, such as those caused by infection.33 In the case of OSA, chronic systemic inflammation may be evident during a dental examination as an unhealthy oral biofilm, which can be caused by the lack of oxygen from sleep apnea.33 Other adverse effects of chronic systemic inflammation from OSA include cardiovascular diseases, mental disorders, sexual dysfunction, digestive problems, diabetes, and high cholesterol.33 If dentists can identify these risk factors during routine examination and screening, appropriate treatment can be provided sooner for improved systemic outcomes.33 When acidic wear is included as part of these examinations, OSA could be identified earlier, which would improve patient quality of life and may, ultimately, save lives.9 Although OSA is typically not diagnosed until polysomnography testing, dental clinicians seem to be ideally positioned for earlier identification of OSA because, unlike primary care physicians, they have the educational background and clinical skills to identify dental erosion.
However, information about OSA seems to be lacking in the dental education curriculum. The importance of early detection is rarely addressed when teaching dental assessment. Documented evidence showing how oral signs of OSA, such as dental acidic erosion, can be used for early detection also seems to be missing from the extant literature. Additional education and training may be necessary for better recognition of dental erosion for OSA screening. To start, better evidence linking dental erosion with OSA before the training and education of dental professionals regarding OSA screening can be improved. Further, evidence-based research studies may also be necessary to address these screening issues for clinical practice.29 To the authors’ knowledge, there are no known screening tools or protocols that include dental acidic erosion to identify the presence or risk of OSA. Therefore, the purpose of this descriptive, cross-sectional pilot study was to describe how a small sample of Texas dentists use dental acidic erosion to screen for OSA.
METHODS
Study Design
A descriptive, cross-sectional survey design was used to evaluate the use of dental acidic erosion when screening for OSA. An online, anonymous 20-question survey was used. Participation was voluntary, and no incentives were offered for completing the survey. No personal or identifying information was collected. A.T. Still University’s Institutional Review Board (IRB) approved the study, and participants provided informed consent before participation. After IRB approval, the study was conducted in the fall of 2023 with data collection for 9 weeks.
Participants
Potential participants were Texas dentists who were part of the Central Texas Dental Society (CTDS). Licensed general dentists practicing in Texas who were members of CTDS, were eligible for participation. Dentists who were not general dentists, such as instructors, retirees, or specialists who did not routinely perform oral examinations for general treatment, were excluded. Examples of specialist dentists excluded were endodontists, orthodontists, periodontists, and oral surgeons. Potential participants were identified through email communication with the CTDS leadership. Once permission was obtained, a study recruitment email was sent to CTDS members.
Study Survey
The 20-question novel survey was specifically developed for the current study and hosted in Qualtrics survey software (Seattle, WA). A panel of four CTDS dentists, independent of the study, reviewed the survey to establish content validity. The survey was estimated to take no longer than 15 minutes to complete. Participants were allowed to skip questions and leave them unanswered, if desired.
The survey contained 3 demographic questions, 11 questions about OSA, and 6 questions about dental acidic erosion. There were 5 dental school curriculum and 2 continuing education questions embedded in these 20 questions. Demographic questions asked participants whether they had received their dental degree in Texas, were a general dentist, and the number of practice years as a licensed dentist. For questions about OSA and dental acidic erosion, answer options included dichotomous (yes, no) responses and Likert-like responses. Likert-like questions asked participants about their comfort level screening for OSA and discussing OSA risk factors. Dichotomous questions asked participants about their OSA screening practices. Specifically, they were asked if they used each of the following OSA screening tools: NoSAS (Neck circumference, Obesity, Snoring, Age, Sex), ESS (Epworth Sleepiness Scale), STOP (Snoring, Tired, Observed, Pressure), STOP-BANG (Body Mass Index, Age, Neck size, Gender), Berlin, and MVAP (MultiVariable Apnea Prediction). Furthermore, participants were asked whether they thought screening was important, if they screened for OSA, thought erosion was important, tracked erosion, and checked sleep quality. One educational question used a dichotomous (yes, no, unsure) response option. Definitions for dental acidic erosion and attrition were not defined for participants, but they were asked if they could recognize the difference between the two. 12 The complete survey is available for review (Figure 1).
Data Collection
The study survey was emailed to general dentists in Texas who were members of CTDS. The initial email described the study, its reasoning and objective, and specified that participation was voluntary and anonymous. Additionally, the email explained the results may be published. Contact information was also provided for survey result requests. The email contained a hyperlink and QR code that took interested participants to the survey. Potential participants were also informed in the recruitment email that informed consent for study participation was implied by clicking on the hyperlink or scanning the QR code. Follow-up emails were sent to all potential participants every 2 weeks until the roughly 9-week data collection period concluded.
Data Analysis
Survey responses were summarized using frequencies and percentages; number of practice years as a licensed dentist was summarized using mean and standard deviation (SD). Frequency distribution as percentages, central tendency, and range were used to describe the ordinal data (ie, data from Likert-like questions) to indicate the variability. SPSS version 29.0 (IBM Corp., Armonk, NY) was used for all analyses.
RESULTS
Participant Characteristics
Survey Responses
Of the 28 participants, 25 (89.3%) indicated that screening for OSA was important, with 13 (46.4%) reporting they routinely screened for OSA (Table 1). Regarding comfort levels, approximately a third of patients (9 of 28, 32.1%) were neither comfortable nor uncomfortable screening for OSA, and most (10 of 26, 35.7%) were extremely comfortable about discussing OSA risks (Table 2). Most participants (24 of 26, 85.7%) recognized erosion, with 12 (42.9%) indicating it was an important aspect of OSA screening (Table 1). Most participants (19 of 26, 67.9%) did not track erosion or ask about sleep quality (13 of 25, 46.4%). Of the 13 participants who routinely screened for OSA, 8 (28.6%) reported using the STOP-BANG questionnaire. Regarding dental school curricula, most patients (15 of 26, 82.1%) reported they had no sleep apnea instruction in dental school. Of those who did, 16 (57.1%) reported it was not sufficient.
Figure 1.
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Table 1.
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Table 2.
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DISCUSSION
Approximately half of the dentists in the current study reported screening for OSA, and almost a third used the STOP-BANG questionnaire for screening. The remaining participants reported using other available tools. None of the six screening tools use dental erosion identification as part of the screening process. The existing tools use investigative questions that can lead to inaccurate patient responses. For example, questions addressing awareness of snoring, acid reflux, and any obstructive or nonbreathing during sleep could result in delayed or nondiagnosed sleep apnea due to the patient's inability to reliably ascertain or address these issues while in a sleep state. The addition of using dental erosion as part of the screening process is a physical attribute that does not rely on the patient’s recall ability or their awareness.
Results of the current study may also be explained by the existing relevant literature, which does not sufficiently address the relationship between GERD, OSA, and dental acidic erosion. For example, previous studies15, 17, 18, 21 failed to show the necessity of using dental acidic erosion for screening purposes or its relation to OSA. During apnea episodes, acid reflux forces gastric acid into the mouth, causing dental acidic erosion.9 Although several researchers7-11, 16, 19 have reported a relationship between GERD and OSA and showed clinical evidence of acid exposure to teeth, this information was not connected to improved screening practices for potential OSA. The failure to recognize these relationships is problematic, especially given that an increase in reflux has been correlated with moderate to severe sleep apnea and body mass index.6-8
From an educational perspective, there needs to be better recognition that GERD causes dental erosion resulting from OSA. In one study,31 authors reported the severity of tooth wear was associated with corresponding severity in OSA. The clinical signs of acidic erosion can be visually seen on the dentition through such characteristics as cupping or flattening of the teeth.12, 31 These signs are different from dental attritional wear caused by grinding of the teeth.14 Therefore, education and training for recognizing the conditions of acidic erosion from GERD caused by OSA, and how they differ from grinding attrition, can aid in earlier OSA detection.
Similarly, it would be beneficial to increase dental provider awareness of the relationship between OSA and dental acidic erosion. Research suggests many dental education curricula provide insufficient education and training for improving clinical evidence-based practice for screening and treatment of OSA.5, 25, 26, 29, 30 With a stronger foundation in evidence-based practice, dental providers would be better able to detect OSA for early referral to a medical professional for diagnosis and treatment. The limited dental education for OSA can also affect provider confidence. For example, Shinde et al26 reported reduced confidence for recent dental graduates regarding their ability to detect and screen for OSA. Patients also tend to have a lack of awareness of OSA and its associated risks.3, 20-22 When dental providers have better awareness of OSA, they can use visual clinical signs to identify OSA and educate patients about these signs. In that way, providers do not have to rely on patients asking questions about OSA symptoms or base treatment options from inaccurate patient responses due to the inability to recognize symptoms.
When a dental clinician has potential evidence of OSA, there should be a standardized protocol for referring patients to medical professionals for a diagnosis of OSA. In the current study, most participants reported referring patients to a primary care physician but not to a gastroenterologist. A gastroenterology referral is more likely to identify early esophageal and throat tissue changes, such as cancerous lesions, caused by repetitious acid exposure. When patients are unaware of the presence of repetitious acid exposure, the importance of a referral beyond a primary physician is heightened.
Patient awareness and education may increase the likelihood of a medical referral follow-up. When suggested by a dental professional, patients were 10 times more likely to follow up with a referral for evaluation by a primary care physician.3 When dental providers contribute in this way to an early medical diagnosis of OSA, their referral can have a profound effect on the quality of life of their patients by facilitating early and appropriate treatment.
Ultimately, the dental profession should consider developing a universal screening tool, so practitioners have a comprehensive approach for routinely examining patients for OSA. Because tooth surfaces are visually examined by dental providers during routine examinations, it would be convenient for them, and advantageous for their patients, to incorporate screening for dental acidic erosion into the existing examination process. After development and testing of this screening tool, practicing dentists and dental students could be instructed on its use. Ideally, the tool would become a standard element of the dental education curriculum. In addition to the screening tool, dental providers would also benefit from additional training to educate patients on risk factors, potential outcomes, and treatment options of OSA. Further research is warranted to develop and assess the validity and reliability of this important screening tool. Once a valid tool is developed, future research could be conducted to investigate the dental school curriculum to determine the best method of incorporating education on dental acidic erosion identification, its relationship to OSA, and use of the newly developed screening tool. Furthermore, researchers should investigate the best methods for increasing patient awareness of OSA. For better interprofessional collaboration in the diagnosis and treatment of OSA, further research could investigate the referral protocols for patient follow-up with primary care and gastroenterology providers; this research could identify best-practice methods for increasing the speed of diagnosis and treatment.
The current study has limitations. Because the current survey was anonymous, participants could have completed the survey more than once, and analyses did not account for potential duplicate responses. In addition, the sample size was small, and participants were from a specific region of Texas, which limits the generalizability of the study findings. The lack of generalizability could also contribute to self-selection bias created by participation from dentists who were interested in the surveyed topic or by selecting answers based on expectancy (e,i Hawthorne effect). Further research is warranted with a larger, more diverse sample to improve the generalizability of study findings and to create a more robust foundation for additional research related to OSA screening education for dental students, and the development of a valid, reliable OSA screening tool using dental acidic erosion for current practitioners.
In conclusion, despite the limitations of the current study, and the existing knowledge that the health of the oral cavity plays an important role in systemic health, the current findings suggest there may be little or insufficient awareness among Texas dentists regarding the use of dental acidic erosion for the identification of OSA and its systemic effects. Furthermore, these findings suggest a lack in dental education curriculum related to the association between dental acidic erosion and OSA. Without this training, dental professionals may fail to recognize the signs of OSA in patients, which may delay essential treatment. However, the development of a new screening tool for OSA that includes dental acidic erosion could improve patient outcomes and quality of life. Future strategies are needed to improve overall awareness of dental providers about the importance of incorporating dental acidic erosion for OSA screening and increase clinician comfort levels by using relevant tools to address the oral and systemic health of patients.
ABBREVIATIONS
CTDS, Central Texas Dental Society
GERD, gastroesophageal reflux disease
OSA, obstructive sleep apnea
SD, standard deviation
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SUBMISSION & CORRESPONDENCE INFORMATION
Submitted December 19, 2024
Submitted in final revised form June 19, 2025
Accepted for publication December 12, 2025
Address correspondence to: Jeffrey L. Alexander, PhD. Email: jalexander@atsu.edu
DISCLOSURE STATEMENT
The current study was conducted through membership email of The Central Texas Dental Society for fulfilling the applied research project requirements of A.T. Still University Doctor of Health Science Degree.Authors report no conflicts of interest.
ACKNOWLEDGMENTS
The authors thank Deb Goggin for her exceptional assistance with editing and preparing the manuscript for publication, and we would like to express our gratitude to Dr. Jane Parks, former acting president of The Central Texas Dental Society (CTDS), for helping with participant recruitment from CTDS’s membership.
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